phantom fat and body dysmorphia after weight loss

‘Phantom fat’: When you still feel oversized even after losing weight


February 23, 2016

Body dysmorphic disorder is less about appearance than anxiety about it.


Some people who have lost weight have trouble embracing their new, slimmer shapes. They may still perceive themselves as very heavy, even when the reflection in the mirror reveals a much smaller person.

This phenomenon is sometimes called “phantom fat” or “phantom fat syndrome.” The medical term is body dysmorphic disorder, said Giovanni M. Billings, Psy.D., a psychologist who works with surgical weight loss patients. The disorder can involve other aspects of a person’s self image, not just weight.

“When people have body dysmorphic disorder, they are preoccupied with something about their physical appearance they perceive as a flaw, even when that ‘flaw’ is not observable to others,” Billings said. “This preoccupation might include repeatedly checking a mirror, seeking reassurance from others, or mentally comparing themselves to other people. An example of this might be a body builder who never sees himself as big enough, so he works out constantly to address this perceived flaw in his appearance.”

Image vs. reality

Why would people who have lost weight still perceive themselves as very large or heavy?

“While weight can quantified by a stepping on a scale, a person’s self-image is a more abstract thing,” Billings said. “Our beliefs, past experiences, relationships, cultural context and behavior all play a part in how we think and feel about ourselves.” If some of those areas haven’t changed despite the weight loss, he said, a person might still feel the same way about themselves as they did when they were heavier.

The people most likely to experience this distorted body image are those with depression or obsessive-compulsive disorder, said John Cleek, M.D., a bariatric surgeon. They tend to zero in on imperfections and perceive them as major flaws.

The seeds of the problem are present before their weight loss, Cleek said; the disorder has more to do with psychology than with a change in size. It’s a rare experience, affecting perhaps 3 percent of people who have lost a great deal of weight, though Cleek noted that there may be more who don’t admit to it.

The amount of weight someone’s lost doesn’t seem to influence whether they develop the disorder, he added. For example, he recalled a medical weight loss patient who had a body mass index (BMI) of 27. That indicates excess weight but not obesity. But this patient felt obese, and obsessed over losing 1 to 2 pounds per week.

Body dysmorphic disorder somewhat resembles eating disorders in which women, especially, view themselves as too fat when they may be at a normal weight. Unlike anorexia or bulimia, body dysmorphic disorder affects men and women equally, Cleek said. But eating disorders do not appear to be a risk factor, he said.

Signs of body dysmorphic disorder include:

  • Repetitive behaviors, such as compulsive grooming or constantly checking the mirror.
  • Seeking frequent reassurance from other people about appearance.
  • Constant anxiety stemming from thoughts about size and appearance. This is a particularly strong symptom of body dysmorphic disorder. “If an individual becomes consumed with thinking about weight, shape and perceived flaws, it could detract from the ability to focus at work or school or engage in normal daily activities,” Billings said.

How to rid oneself of “phantom fat”

It’s difficult to bring self-perception and reality into alignment.

Some people might need to deal with a relationship in which the person’s weight played a key role, or with past experiences of being bullied or shamed, Billings said. Others may need to practice telling themselves different messages about their size.

“Working on viewing oneself as a whole person with varying parts, interests and facets – as opposed to over-identifying with and/or attaching so much importance on the physical self – could also be helpful,” Billings said.

A therapist can help. Cleek added that antidepressant medications are a common treatment. If you’re unhappy with your appearance even after reaching a healthy weight, it’s time to seek counseling, both doctors said.

After all, being healthy should be about how well you can live your life, Cleek said: “Life is so much more than a pound or two on the scale.”


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Help for those trying to lose weight

Keeping off excess weight is a challenge. People who have maintained their weight loss have many positive things in common. Keeping the kitchen stocked with healthy food always helps. If you’re just starting your weight-loss efforts, exercise is probably one of your goals. Start an exercise routine that’s manageable and not too intense at first.