The right to force feed

[Scooter]

The contention that she has merely a psychiatric disorder rather than a terminal one leads to vicious circularity: "You are not competent to decide that you want to die. How do we know that you are not competent to decide that you want to die? Because you want to die."

No, that is not it at all. Many people can competently make the decision to die precisely because their mental faculties remain completely intact. I doubt very many people would be arguing against the right of a terminal cancer patient to refuse treatment, including nourishment, if that would mean they would die. Anorexia is a disease in which perception is completely divorced from reality i.e. anorexics see themselves as fat even when they look like concentration camp survivors. Such a distortion of perception cannot help but influence a decision of whether one wants to live or die.

[Andrew D]

But no one's perception is perfect. All of us have illusions about ourselves. And all of us have illusions about others.

When we decide to deny someone a right as fundamental as the right to refuse medical treatment on the ground that that person's perceptions disagree with ours, we set out on a perilous road. The relevant inquiry should be whether the person understands the consequences of her or his decision, not whether her or his assessment of the desirability of those consequences agrees with yours or mine.

[BoSoxGal]

The clinically, profoundly depressed person may understand fully that the consequence of starvation - or overdose, or bullet to the brain - is death. That doesn't mean that s/he truly wishes to die, or that the desire to die expressed in the depths of clinical depression is a fully knowing, purposeful competent expression of individual will.

How utterly tragic it would be if society took the position of encouraging or actively facilitating such persons in carrying out their seemingly lucid intent to self-murder; so many special people have suffered the demons of clinical depression.

Ask a person who has been to that dark place and returned if s/he feels in retrospect s/he was making a sane expression of will in expressing the desire to die in that moment in time.

[Gob]

Some one who is severely depressed will not see any hope nor respite from their feelings and may think that only death will offer a way out. Should we allow them to make judgements for themselves while in this state?

I have seen severely depressed people who have been actively suicidal have three courses of ECT and get their full life back. Should we not make that decision of their behalf?

[Scooter]

When we decide to deny someone a right as fundamental as the right to refuse medical treatment on the ground that that person's perceptions disagree with ours, we set out on a perilous road.

Except that we don't deny someone the right to refuse medical treatment on the grounds that that person's perceptions disagree with ours. We do so (in some cases) when those perceptions are objectively divorced from reality. This is the second and final time that I will correct your attempts to move the goalposts, so feel free to continue doing so to your heart's content.

[Big RR]

Scooter--and we decide their perceptions are objectively divorced from reality by what mechanism? It's easy to say that terminally ill people should be allowed to make this decision, but I would bet that is becauuse we agree with the decision . When a person makes a decision that they are competent to make (because they understand the consequences of it), are you really saying we canand should second guess it and say that they would not make that decision if they were in their "right minds"? Yes, depression can color our perceptions, but when do we decide that the dpression is gone and the person should have the right to self-dtermination? When they change their minds?

What sort of objective test would you recommend? I think the point Andrew made, understanding the consequences of their actions, can be objectively applied. What other basis would you use to subvert the will of a person choosing to die?

[Scooter]

When a person makes a decision that they are competent to make (because they understand the consequences of it), are you really saying we canand should second guess it and say that they would not make that decision if they were in their "right minds"?

I believe I pretty clearly stated that a competent person should be able to make whatever decision they wish, and begging the question by defining someone as competent if they understand the consequences of their decision doesn't change that.

A paranoid schizophrenic might be perfectly capable of understanding that putting a gun to his temple and pulling the trigger will kill him, but if the reason he is doing so is because the little man sitting on his shoulder told him it would bring about world peace, the guy is delusional and incapable of making such a decision for himself.

Yes, depression can color our perceptions, but when do we decide that the dpression is gone and the person should have the right to self-dtermination? When they change their minds?

I haven't said anything about depression being a reason for preventing someone from making decisions for him/herself.

What sort of objective test would you recommend?

I believe I already said something about delusions that are objectively divorced from reality. I believe that seeing yourself as a beached whale in the mirror when you're literally nothing but skin and bones
qualifies.

[Gob]

It's an old one, but; an ex client of mine had, before I became involved in his care, been informed by god that he was the second coming of Christ, and that to prove his worthiness he should cut off his genitalia. Not only did he do this, but he rendered them such a mess it would be impossible to reattach them.

To him it was all perfectly logical, correct and a good thing for him to do, god told him so.

[rubato]

Having worked with college students for >10 years I am convinced that most of the time most people who are making suicidal gestures are acting under short-term compulsions and should be prevented; because when the crisis is passed they really want to live. But having said that, there are people who have suffered for a long time with incurable illnesses, mental and other, who I would respect as making a rational choice to end their life.

This anorexic might be one of them.

But to me the limit of our obligation as a society is to assure that the malnutrition itself is not the cause of her desire. Feed her up to some reasonable std and then let her choose.


yrs,
rubato

[Andrew D]

I am not moving the goalposts, Scooter. On the contrary, I agree that people who are

objectively divorced from reality

are not competent to make their own medical decisions.

A person who believes that she weighs 150 pounds despite being confronted with reliable scales showing that she actually weighs 90 pounds is objectively divorced from reality. That person is not competent to make her own medical decisions, at least insofar as those decisions involve her weight. (One's detachment from reality, to be relevant, must have some impact on the decision in question.)

But a person who knows full well that she actually weighs 90 pounds is not objectively divorced from reality. If she wants to weigh 60 pounds, even though she knows that reducing her weight to 60 pounds will probably kill her, that does not show that she is objectively divorced from reality. If she would rather die attempting to weigh 60 pounds than live weighing 90 pounds, that does not show that she is objectively divorced from reality. Rather, it shows that her assessment of the merits of the consequences of her decision -- the merits of dying in the attempt to weigh 60 pounds vs. the merits of living weighing 90 pounds -- differs from the assessment which most of us would make. Given that she understands those consequences, I see no justification for imposing our assessment of the merits of the consequences of her decision upon her.

And this:

A paranoid schizophrenic might be perfectly capable of understanding that putting a gun to his temple and pulling the trigger will kill him, but if the reason he is doing so is because the little man sitting on his shoulder told him it would bring about world peace, the guy is delusional and incapable of making such a decision for himself.

appears to be simply another example of what I already wrote:

There is a case to be made for some people's incompetence to make their own medical decisions. People who are convinced that they are being poisoned by extraterrestrial aliens. People who believe that slitting their wrists will not kill them but will release the homunculi in their veins to liberate humanity. Unconscious people. Etc.

Thus, it appears that our only disagreement is whether a person who is not delusional (or otherwise objectively divorced from reality) should be allowed to refuse medical treatment for reasons which most of us would, in her or his circumstances, find insufficient. The goalpost remains right where it has been.

[Scooter]

Thus, it appears that our only disagreement is whether a person who is not delusional (or otherwise objectively divorced from reality) should be allowed to refuse medical treatment for reasons which most of us would, in her or his circumstances, find insufficient.

No, it appears that our disagreement lies in what the definition of "delusional" is, because I have never said that anyone who was not delusional should be prohibited from refusing medical treatment. However, I would tend to include as delusional those who see themselves as hippopatamus-sized when they look in a mirror, in spite of being dangerously underweight.

[Andrew D]

I would tend to include as delusional those who see themselves as hippopatamus-sized when they look in a mirror, in spite of being dangerously underweight.

Do you mean that when they look in mirrors, their visual perceptions are that they are hippopotamus-sized – like a fun-house mirror? Or do you mean that when they look in mirrors, their visual perception is roughly accurate, but they consider themselves to be hippopotamus-sized compared to what they think that they ought to be? The difference is crucial both to understanding anorexia in the first place and to how we ought to determine whether a person is competent to make her own medical decisions. (I say “her,” because most of those afflicted with anorexia are female.)

A woman stands 5’7” and weighs 100 pounds. Her measurements include no extremes (neither huge- nor tiny-breasted for her size, neither wasp-waisted nor straight vertical from armpits to hips, etc.). She looks into a mirror. She sees a woman with non-extreme measurements within the range which one would expect to see when looking at a woman who stands 5’7” and weighs 177 pounds (or a woman with any extreme measurement).[1]

That is a problem of perception: What she sees is objectively divorced from reality.

Another 5’7” 100-pound woman with non-extreme measurements looks into a mirror. She sees a woman with the non-extreme measurements within the range which one would expect to see when looking at a 5’7” 100-pound woman, but she considers herself “hippopotamus-sized”.

That is not a problem of perception: What she sees is not objectively divorced from reality.

That is a problem of body-dissatisfaction: She perceives reality accurately, but she does not like the reality which she perceives. Her problem is not divorcement from objective reality; her problem – if it is a problem – is subjective distaste for reality.

And there’s the rub, and it is a rub even in an extreme case. Suppose that a 5’7” 100-pound woman sees her ideal body size as that of a 5’7” woman who weighs 78 pounds. We can, I think, safely conclude that a 5’7” 78-pound woman is malnourished and, unless she gains some weight, will probably die.[2] She knows that unless she gains some weight, she will probably die. Nonetheless, she insists on obtaining and maintaining what, to her, is her ideal weight of 78 pounds. (Maybe she is hoping that she will be the rare exception, and that staying at 78 pounds will not kill her; maybe she would rather die at 78 pounds than live at 118 pounds[3]; whatever (provided that it does not involve extraterrestrial aliens, the little man on her shoulder, etc.).)

If we as a society intervene by forcing her – as distinct from attempting to persuade her; I have nothing against that – to gain weight, we will not be protecting her from the consequences of a failure to perceive reality accurately. We will be forcing her to adhere to our subjective, normative, non-objective judgment that living at 118 pounds is better than dying at 78 pounds.

Who are we to do that? Who are we to substitute, by force, our subjective, normative, non-objective judgment about her life for hers? It is, after all, her life, not ours. If we forcibly impose our subjective, normative, non-objective judgment upon her – and her subjective, normative, non-objective judgment be damned – we are treating her life as if it belonged to us rather than belonging to her. What is the justification for that?

And what are the limits of that justification? Vitamin B12 deficiency can kill me by causing pernicious anemia. If the diet which I choose brings about a vitamin B12 deficiency, and I persist in eating that way (and decline shots and supplements and such) even though I am aware that doing so may well kill me, should society force-feed me clams or nutritional yeast?

And why stop with forcing someone to do what he or she, fully aware of the consequences, chooses not to do? Why not force someone not to do what he or she, fully aware of the consequences, chooses to do?

In sum, force-feeding someone whose relevant perceptions are objectively divorced from reality is one thing, and I have no objection to it. (But if someone were to raise an objection which I have not yet considered – and I suspect that there are more than a few of those – I might agree with it.)

But force-feeding someone whose relevant perceptions accord with objective reality is quite another thing. It amounts to force-feeding someone who, perceiving objective reality accurately, makes a subjective, normative, non-objective decision which differs from the subjective, normative, non-objective decision which you or I might well make. That is a road which I am unwilling to travel.

Notes

1. According to the BMI, the 5’7” 100-pound woman is 2.8 BMI points below the bottom of the normal range (15.7 vs. 18.5), and the 5’7” 177-pound woman is 2.8 BMI points above the top of the normal range (27.7 vs. 24.9).

2. Her BMI is a more than one third of the way from the top of the underweight range (18.4) to zero.

3. A 5’7” 118-pound woman’s BMI is 18.5, the very bottom of the normal range.

[Andrew D]

It's unethical to expect medical personnel who swear an oath to preserve life to assist her in dying when she isn't terminally ill.

In my opinion, given that a person is fully cognizant of the consequences of her decision, the decision whether to accept those consequences should be hers alone. It is her life, not anyone else’s

But that does not mean that she should have any unilateral authority to decide what those consequences are. She has, in my opinion, the unilateral authority to prevent her health-care providers from force-feeding her. But whether her health-care providers should be allowed to refuse to give her palliative care – which, even if it does not amount to assist her in dying, surely makes her dying (and, therefore, her choice to die) easier – is another matter.

It may be that as a matter of public policy, we should permit her health-care providers to say “Fine. If you want to die, have at it. But if you refuse the care which will actually sustain your life, we are not going to continue to provide the palliative care which makes it easier for you to die. We have available the care which will help you continue to live. If you insist on refusing it, then you can go home to die in lonely misery.”

On the other hand, it may be that as a matter of public policy, the better judgment (at least morally) is that we should not turn a blind eye to someone’s dying a lonely, miserable death. It may be that the better – better for us – course of action would be to provide her palliative care even while we make clear to her how wrong we think her choice to be.

I incline toward the latter, but I see merit in the former. Either way, we have some control over some of the consequences of her decision. And she can take those consequences or leave them. Given that she grasps those consequences – including the fact that some of those consequences may really suck – the ultimate decision should be hers.

[Andrew D]

I've known recovered anorexics; one struggles with the underlying issues forever, as with any serious psychiatric disorder - but one can still live a life of good quality.

The clinically, profoundly depressed person may understand fully that the consequence of starvation - or overdose, or bullet to the brain - is death. That doesn't mean that s/he truly wishes to die, or that the desire to die expressed in the depths of clinical depression is a fully knowing, purposeful competent expression of individual will.

* * *

Ask a person who has been to that dark place and returned if s/he feels in retrospect s/he was making a sane expression of will in expressing the desire to die in that moment in time.

What about the person who does not return? It may be that a profoundly depressed person does not truly wish to die. But it just as much may be that he or she does truly wish to die. What about the person whose desire to die, even when expressed in the depths of clinical depression, really is a fully knowing, purposeful, and competent expression of her or his individual will?

Yes, a clinically depressed person struggles with the underlying issues forever. And that precisely presents the problem.

Does not a person have the right to give up on struggling? How should we respond to someone who says:

I am done with struggling. I have tried all of your medications, and they do not work. You have run out of them, so what should I do now?

Every morning (or afternoon), I wake up to anguish. The fact of waking up is a sentence to yet another day of unalleviable misery.

Not that my sleeping is any better. When I sleep, I suffer through incomprehensible miseries. When I wake up, I suffer through comprehensible miseries.

I have tried. I have taken the pills. I have bared my soul (to the extent to which I can find it) in our one-on-one sessions. I have participated in – and I mean really participated in, not just attended – the support groups. I have modified my behavior in all the ways which have been suggested to me and in some ways which I found/figured out for myself.

None of it has worked. And we have tried everything – everything that I know of, and you have also run out of alternative treatments. (No, acupuncture did not work either; nor did internalizing meditation; nor did the vegan diet; nor did beating drums in the forest; nor did bathing in the Ganges; nor did anything else.)

You tell me to keep on struggling. As if some dawn were just waiting there for me to climb the mountain and see it on the horizon.

You know what? I have climbed mountains over and over and over again. Sisyphus is a piker in the mountain-climbing department. And there has never been any dawn. There has never been anything even remotely resembling a dawn.

I am tired of struggling. I am tired of climbing mountains. I am tired of seeing no dawns.

I am tired of puking my lunch after I take your prescribed medications. I am tired of stumbling around in a drug-induced stupor – induced by you – and I am tired of not going to sleep after I take the medications which I am instructed to take only at bedtime, because they will make me sleepy.

Ha! Maybe in the wettest of my dreams. (As if I could still have wet dreams.)

I am just so tired. So bone-drenchingly, foot-stumblingly tired. Do you like poems? Here is a bit of one for you:

“I am tired of tears and laughter,
And men that laugh and weep
Of what may come hereafter
For men that sow to reap:
I am weary of days and hours,
Blown buds of barren flowers,
Desires and dreams and powers
And everything but sleep.”

I have had more than enough of struggling. (“After all, I’ve tried for three years" – well, more like forty – "seems like ninety ….”)

And you talk about hope? You have the temerity, the unmitigated gall, to lecture me about hope?

I have a hope – a single, I-wish-it-were-unwavering-but-it-actually-wavers-constantly hope:

“From too much love of living,
From hope and fear set free,
We thank with brief thanksgiving
Whatever gods may be
That no life lives forever;
That dead men rise up never;
That even the weariest river
Winds somewhere safe to sea.”

Who are you to block my safe, weary winding to whatever sea there may be?

Who are you to say “You have not struggled enough; you need to struggle more”?

Where is your ‘life of good quality’? It is not my life. My life sucks. And I see nothing even resembling a reasonable possibility that my life will ever not suck.

So who are you to force me to continue living it?

What answer have we for that person?

[rubato]

I would say that the means and knowledge to kill yourself is available to most people. There are more than enough accessible tall buildings, bridges, the pacific ocean (around here) is deep and cold enough, guns are cheap and plentiful, the chemical combinations with a high probability of causing death are well known, the effects of driving at high speed into an overpass, river, ocean are sufficiently lethal.

Therefore anyone who uses means with a poor likelihood of success, when a great likelihood of success was so easy, is not especially clear about their goals or not especially clear about anything and ought to be distracted for some period of time even if that appears to be a temporary attenuation of their personal and glorious autonomy as conscious beings.

yrs,
rubato

[Jarlaxle]

What answer have we for that person?

A fifth of Jack Daniels a bottle of sleeping pills, and a tank of nitrous oxide.

[BoSoxGal]

'Resume'

Razors pain you;
Rivers are damp;
Acids stain you;
And drugs cause cramp;
Guns aren't lawful;
Nooses give;
Gas smells awful;
You might as well live.

Dorothy Parker

[Andrew D]

Anorexics, on the whole, do not “see themselves” as larger/heavier than they actually are. On the whole, they “see themselves” has larger/heavier than they want to be. And that is a very different thing.

I would tend to include as delusional those who see themselves as hippopatamus-sized when they look in a mirror, in spite of being dangerously underweight.

Do you mean that when they look in mirrors, their visual perceptions are that they are hippopotamus-sized – like a fun-house mirror? Or do you mean that when they look in mirrors, their visual perception is roughly accurate, but they consider themselves to be hippopotamus-sized compared to what they think that they ought to be? The difference is crucial … to understanding anorexia ….

* * *

[One can have] a problem of perception: What [one] sees is objectively divorced from reality.

* * *

[Or one can have] a problem of body-dissatisfaction: [One] perceives reality accurately, but [one] does not like the reality which [one] perceives.

Perceptual problems are generally measured by having each subject estimate her body size and comparing that estimate to the subject’s actual body size.[1] The most common term for subjective dislike of one’s body is “body dissatisfaction”.[2] It is also known as “cognitive distortion,”[3] “‘cognitive-evaluative dysfunction,’”[4] and “cognitive-evaluative dissatisfaction”.[5] “Body image” is commonly used as a blanket term embracing both one’s perception of one’s body and one’s attitude towards one’s body, as in “perceptual and attitudinal body image”.[6] But “body-image dissatisfaction” has been used to refer only to body dissatisfaction as distinct from the perceptual “dysfunctional size estimation”.[7]

Regardless of some inconsistency in terminology, however, the difference between perceptual problems and body-dissatisfaction problems permeates the study of eating disorders. “The concept of body image is thought to consist of two components: body size perception and attitudes towards the body. Correspondingly, two distinct modalities of body image dysfunction seem to be relevant for anorexia nervosa: perceptual body size distortion and cognitive-evaluative dissatisfaction.”[8] “The perceptual distortion occurs when an observer is unable to gauge her body size accurately, and the cognitive distortion is when an observer can accurately estimate her size, but may be excessively dissatisfied with her size, shape or some other aspect of her appearance.”[9]

Into the late 1990s, the results of studies of perceptual problems were “contradictory and inconclusive”.[10] In part, that was because “[m]ost of th[o]se studies were done using various body size estimation techniques”.[11] Even “[t]he most realistic approach [ – ] the distorting video technique or DVT [which] alters a picture of the subject’s body … by distorting along the horizontal or vertical axis (i.e. either stretching or compressing the body vertically or horizontally) [ – ] do[es] not accurately mimic the pattern of shape change produced by changing body mass.” Therefore, “if observers are asked to estimate their body size they may do so on the basis of minimizing the distortion rather than setting the body size to what they believe it to be.”[12]

Nonetheless, in 1997, “a meta-analysis of 66 investigations (from 1974 to 1993) of perceptual and attitudinal body image among patients with anorexia nervosa or bulimia nervosa” found that “[a]ffect sizes for perceptual distortion were moderate, ranging from .61 to .64 among women with eating disorders compared to control groups[, whereas b]ody dissatisfaction measures yielded consistently larger sizes, ranging from 1.10 to 1.13. Thus, women with clinical eating disorders experience attitudinal body dissatisfaction to a much greater degree than they perceptually overestimate their body size.”[13]

More recent research casts doubt on whether perceptual problems matter play any significant role in anorexia nervosa at all. A 1999 study of bulimic and anorexic patients concluded that “there is no evidence for a serious impairment of body perception (size estimation) in eating-disordered patients, but rather for a disturbance in the emotional aspect of body image, as expressed in negative body attitudes. Body size perception does not appear to be a predictor of treatment outcome in eating disorders.” Rather, “both bulimic and anorexic patients, in spite of exhibiting negative body attitudes, do not present distorted body perception … in the estimation of their own body size”; “the explanation for the “fear of becoming fat” among eating-disordered patients does not arise from a pathological overestimation of their own body size.”[14]

Three twenty-first-century studies indicate that perceptual problems play no significant role in anorexics’ body-image problems. A 2001 review of “the numerous methods of assessing body image used in recent studies on anorexia nervosa” concluded “that body image disturbance is not due to any perceptual deficit, but is based on cognitive-evaluative dissatisfaction.”[15]

A 2003 study – using a technique far more sophisticated than the DVT – of anorexic, bulimic, and control subjects (called “observers”) concluded that “all three observer groups tend to overestimate their body size, but not significantly so.”[16] That study also measured each observer’s actual body mass index (“BMI”), each observer’s estimate of her BMI, and the BMI of each observer’s ideal body. The anorexics stood out in two ways. First, the anorexics are more comfortable with their bodies than are the bulimics or the control observers: Their ideal BMIs are not significantly different from their actual or self-estimated BMIs, whereas the control observers’ and the bulimics’ respective ideal BMIs are significantly lower than both their actual and their self-estimated respective BMIs.[17] Second – driving home the point that the anorexics’ body-image problems are body-dissatisfaction problems, whereas “the control and bulimic observers prefer an ideal body with a BMI of 20, which is at the lower end of the ‘normal’ BMI range … the anorexics ideal BMI is 15, which is on the border between the emaciated and underweight BMI categories.”[18]

Finally, just this year, a study flatly concluded that “[t]here is no systematic sensory-perceptual deficit in AN [anorexia nervosa] patients ….” Moreover, “[ b]ody-image dissatisfaction in AN patients [is] not [even] related to dysfunctional size estimation.”[19]

On the whole, anorexics are not objectively divorced from reality. They just do not like the reality which they accurately perceive. We should bear that in mind when we make public-policy decisions.

Notes

1. See, e.g., Goldzak-Kunik et al., “Intact sensory function in anorexia nervosa,” American Journal of Clinical Nutrition (February 2012) (abstract); Tovee et al., “Measurement of body size and shape perception in eating-disordered and control observers using body-shape software,” 94 British Journal of Psychology (2003) 501, 503; Skrzypek et al., “Body image assessment using body size estimation in recent studies on anorexia nervosa: A brief review,” 10 European Child & Adolescent Psychiatry Number 4 (2001) 215 (abstract); Fernandez-Aranda et al., “Body Image in Eating Disorders and Analysis of Its Relevance: A Preliminary Study,” 47 Journal of Psychosomatic Research, Number 5 (1999) 419, 419-420; Cash and Strachan, “Body Images, Eating Disorders, and Beyond” in Lemberg, ed., Eating Disorders: A Reference Handbook (Oryx Press 1999) 32; Probst, et al., “The significance of body size estimation in eating disorders: its relationship with clinical and psychological variables,” 24 International Journal of Eating Disorders, Issue 2 (September 1998) 167 (abstract); Altabe and Thompson, “Size estimation versus figural ratings of body image disturbance: Relation to body dissatisfaction and eating dysfunction,” 11 International Journal of Eating Disorders, Issue 4 (May 1992) 397 (abstract).

2. See, e.g., Fernandez-Aranda et al., “Body Image in Eating Disorders and Analysis of Its Relevance: A Preliminary Study,” 47 Journal of Psychosomatic Research, Number 5 (1999) 419, 425; Probst, et al., “The significance of body size estimation in eating disorders: its relationship with clinical and psychological variables,” 24 International Journal of Eating Disorders, Issue 2 (September 1998) 167 (abstract); Altabe and Thompson, “Size estimation versus figural ratings of body image disturbance: Relation to body dissatisfaction and eating dysfunction,” 11 International Journal of Eating Disorders, Issue 4 (May 1992) 397 (abstract).

3. Tovee et al., “Measurement of body size and shape perception in eating-disordered and control observers using body-shape software,” 94 British Journal of Psychology (2003) 501, 502.

4. Tovee et al., “Measurement of body size and shape perception in eating-disordered and control observers using body-shape software,” 94 British Journal of Psychology (2003) 501, 502 (citing “Cash & Brown, 1987; Cash & Deagle, 1997; Gardner, 1996; Slade, 1988”).

5. Skrzypek et al., “Body image assessment using body size estimation in recent studies on anorexia nervosa: A brief review,” 10 European Child & Adolescent Psychiatry Number 4 (2001) 215 (abstract).

6. Cash and Strachan, “Body Images, Eating Disorders, and Beyond” in Lemberg, ed., Eating Disorders: A Reference Handbook (Oryx Press 1999) 32; see also Fernandez-Aranda et al., “Body Image in Eating Disorders and Analysis of Its Relevance: A Preliminary Study,” 47 Journal of Psychosomatic Research, Number 5 (1999) 419, 420 (“research on body image should make use of several assessment techniques that take into account both perceptual and emotional aspects”).

7. Goldzak-Kunik et al., “Intact sensory function in anorexia nervosa,” American Journal of Clinical Nutrition (February 2012) (abstract).

8. Skrzypek et al., “Body image assessment using body size estimation in recent studies on anorexia nervosa: A brief review,” 10 European Child & Adolescent Psychiatry Number 4 (2001) 215 (abstract).

9. Tovee et al., “Measurement of body size and shape perception in eating-disordered and control observers using body-shape software,” 94 British Journal of Psychology (2003) 501, 502 (citations omitted).

10. Tovee et al., “Measurement of body size and shape perception in eating-disordered and control observers using body-shape software,” 94 British Journal of Psychology (2003) 501, 502 (citing “Bowden, Touyz, Rodriguez, Hensley, & Beaumont, 1989; Collins et al., 1987; Fernandez, Probst, Meerman, & Vandereycken, 1994; Gardner & Bokenkamp, 1996; Garner, Garfinkel & O’Shaughnessy, 1985; Meerman, 1983; Probst, VanCoppenolle, Vandereycken, & Goris, 1992; [and] Probst, Vandereycken, & VanCoppenolle, 1997”).

11. Tovee et al., “Measurement of body size and shape perception in eating-disordered and control observers using body-shape software,” 94 British Journal of Psychology (2003) 501, 502 (citing “Bowden, Touyz, Rodriguez, Hensley, & Beaumont, 1989; Collins et al., 1987; Fernandez, Probst, Meerman, & Vandereycken, 1994; Gardner & Bokenkamp, 1996; Garner, Garfinkel & O’Shaughnessy, 1985; Meerman, 1983; Probst, VanCoppenolle, Vandereycken, & Goris, 1992; [and] Probst, Vandereycken, & VanCoppenolle, 1997”).

12. Tovee et al., “Measurement of body size and shape perception in eating-disordered and control observers using body-shape software,” 94 British Journal of Psychology (2003) 501, 502 (both quotations).

13. Cash and Strachan, “Body Images, Eating Disorders, and Beyond” in Lemberg, ed., Eating Disorders: A Reference Handbook (Oryx Press 1999) 32 (both quotations).

14. Fernandez-Aranda et al., “Body Image in Eating Disorders and Analysis of Its Relevance: A Preliminary Study,” 47 Journal of Psychosomatic Research, Number 5 (1999) (abstract) (first quotation), 425 (second quotation), and 427 (third quotation).

15. Skrzypek et al., “Body image assessment using body size estimation in recent studies on anorexia nervosa: A brief review,” 10 European Child & Adolescent Psychiatry Number 4 (2001) 215 (abstract) (both quotations).

16. Tovee et al., “Measurement of body size and shape perception in eating-disordered and control observers using body-shape software,” 94 British Journal of Psychology (2003) 501, 501.

17. See Tovee et al., “Measurement of body size and shape perception in eating-disordered and control observers using body-shape software,” 94 British Journal of Psychology (2003) 501, 509-510.

18. See Tovee et al., “Measurement of body size and shape perception in eating-disordered and control observers using body-shape software,” 94 British Journal of Psychology (2003) 501, 501.

19. Goldzak-Kunik et al., “Intact sensory function in anorexia nervosa,” American Journal of Clinical Nutrition (February 2012) (abstract).