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A Literature Review on Handwriting, Anorexia, and Body-Oriented Therapy
Miriam Goldstein
Vanderbilt University

Author Note
This paper was prepared for Psychology 352: Body and Self in the Brain, taught by
Professor Sohee Park.

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Abstract

The purpose of this paper is twofold. Firstly, it aims to investigate the existing research on bodyoriented therapies, body size distortion in anorexia nervosa, and the relationship between ones
handwriting and ones sense of self in space, with special interest in studies where these areas
overlap. Secondly, the paper proposes new studies that can be developed to further investigate
the aforementioned phenomena and to develop treatments for anorexia nervosa an eating
disorder for which there are currently few truly effective treatment options based on this
increased understanding of how manipulations of the body can influence the mind and ones
sense of self. The available literature in this area of study is minimal, but the studies proposed in
this paper should help to carry the research into its next phase.
Keywords: eating disorders, anorexia nervosa, autism spectrum disorder (ASD),
Parkinsons disease (PD), peripersonal space, proprioception, interoception, embodiment,
handwriting, graphology, micrographia, macrographia, body-oriented therapy, mindfulness

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Write Up: A Literature Review on Handwriting, Anorexia, and Body-Oriented Therapy


In recent years, the research on the connection between the body, the brain, and ones
sense of self has begun to take off. Perhaps due to or co-occurring with the rise of dialectical
behavior therapy (DBT) and other mindfulness-based therapies that require patients to step away
from themselves (a process which of necessity recognizes the existence of a rupturable
connection between the mind and body), many researchers have expressed increased interest in
studying disordered separation from the self, as well as more normative dissociation from the
body and self. Even the general public finds fascination with the relatively simple possibility
that, by changing ones body, one can alter his or her well-being and live a happier, more
productive life. The ever-popular TED Talk series recently welcomed social psychologist Amy
Cuddy to their stage, where she gave a lecture on what she calls power poses, holding ones
body in positions that imply status and have been shown to make individuals feel more confident
in themselves (Carney, Cuddy, & Yap, 2010). Given this and other new research on the ability for
changes in the body to influence emotions including evidence that forced smiling might be
helpful when encountering stressors and that people instructed to hold warm drinks can be made
to feel warmer towards those around them it seems possible that effective psychological
treatments utilizing this newfound knowledge could be developed (Davis, Senghas, Brandt, &
Ochsner, 2010; Herbert & Pollatos, 2012; Jostmann, Lakens, & Schubert, 2009; Kraft &
Pressman, 2012; Laird & Lacasse, 2014; Williams & Bargh, 2008).
Many disorders, psychological and otherwise, can involve a perception of body and/or
self that strays from the typical. Included in this category are schizophrenia, autism, depression,
posttraumatic stress disorder (PTSD), anorexia nervosa, body dysmorphic disorder, and
Parkinsons disease (PD) (Cascio, Foss-Feig, Burnette, Heacock, & Cosby, 2012; Case, Wilson,

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& Ramachandran, 2012; Feeny, Zoellner, Fitzgibbons, & Foa, 2000; Kaplan, Enticott, Hohwy,
Castle, & Rossell, 2014; McNamara, Durso, & Harris, 2006; Soffer-Dudek, 2014; Thakkar,
Nichols, McIntosh, & Park, 2011). Although the research in this area is sparse, a number of these
disorders appear to afflict their sufferers with abnormal handwriting size (Beversdorf et al., 2001;
Johnson et al., 2013; Oliveira, Gurd, Nixon, Marshall, & Passingham, 1997). Among them is
anorexia nervosa, an eating disorder that is notoriously difficult to treat and has a greater
mortality rate than any other mental illness (Insel, 2012; Sekar, Arcelus, & Palmer, 2010). For
this reason alone, mental health professionals and researchers should always be on the lookout
for new potential therapies that can help combat this devastating disorder.
Considering the increased understanding of the bodys ability to influence ones
cognitions and self-concept, the experimentation with various treatments based on this
awareness, and the need to develop more effective therapies for anorexia, it makes sense to
explore treatment options that focus on altering the distorted body image that accompanies this
eating disorder. If power poses allow individuals to increase their confidence and decrease
their stress levels, it is possible that a therapy requiring patients with anorexia nervosa to enlarge
their handwriting could make a difference in how they perceive their body size, and in turn, may
help alleviate other symptoms of anorexia. To that end, this literature review will examine
studies that focus on how anorexia affects awareness of body size, how body-oriented therapies
have already been tested on anorexia nervosa and other eating disorders, how handwriting affects
anorexia and other disorders that involve a distorted sense of self, and how it is possible to
compel individuals to alter their handwriting size. Ultimately, this paper will also propose new
research studies that should be conducted in order to test the feasibility and efficacy of
handwriting-based therapies for eating disorders and beyond.

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Review of Literature

Anorexia Nervosa and Body Size Distortion


It is no secret that those afflicted by anorexia nervosa and eating disorders have distorted
body images, with many having false beliefs about their body size, believing that they take up
more space than they actually do (Cash & Deagle, 1996; Garner, Garfinkel, Stancer, &
Moldofsky, 1976; Heilbrun & Friedberg, 1990; Penner, Thompson, & Coovert, 1991; Slade,
1985; Smeets, Smit, Panhuysen, & Ingleby, 1997). As early as 1998, investigators were
suggesting that the research on eating disorders move away from a focus on distortion of body
image alone which Probst, Vandereychken, Van Coppenolle, and Pieters (1998) found to
overemphasize the visual aspect of self-perception and to instead focus on what they termed
body experience: the physical, emotional, and cognitive aspects of bodily perception. In the
coming year, Smeets, Ingelby, Hoek, and Panhuysen (1999) designed a study with the goal of
determining whether individuals with anorexia consider themselves to be fatter because they
perceive themselves as fatter, or whether their overestimation of body size derives from a
reconstruction of the image of themselves, ultimately finding more proof for the latter concept.
However, once again, this study focused more on the visual component of self-perception rather
than deferring to the concept of self and body that derives from more interoceptive factors. A
study by Skrzypek, Wehmeier, and Remschmidt (2001) took Probst et al.s suggestion of moving
away from the more tangible, visual construction of body image by examining both perceptual
functions and attitudinal aspects of body size estimation but still concluded that little was
known about how body image disturbance in anorexia operates and that much further
investigation into this area would be necessary (p. 218). Epstein et al. (2001) came to a similar
decision.

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In the last five years, research on distorted body image in anorexia has shifted back into
the realm of perceptual distortions. Guardia et al.s (2010) study involving patients with anorexia
nervosas ability to judge whether or not they could pass through an aperture of a certain size
concluded that, because participants overestimation of body size correlated with duration of
illness and degree of body dissatisfaction, anorexia may involve a deficit in neural processing of
body dimensions, such as a central nervous system that has not updated the patients body
schema after rapid weight loss. Case et al. (2012) returned to a proposal of deficits in visual
processing. In their study, they found that patients with anorexia nervosa demonstrate a reduced
ability, as compared to the normal population, to perceive the smaller of two objects of equal
weight but different sizes as heavier. They attributed these findings to decreased integration of
visual and proprioceptive information in individuals with anorexia and proposed the possibility
of visual or visuo-tactile integration therapies to reconfigure the perception of body weight and
size in patients with anorexia nervosa. Keizer, Smeets, Postma, van Elburg, and Dijkermans
(2014) recent study involving the rubber hand illusion (through which simultaneous stroking of
an individuals own hidden hand and a fake hand produces the sensation of ownership of the
artificial hand) determined that because individuals with anorexia appear to be more responsive
to the rubber hand illusion (more readily incorporating the rubber limb into their body schema),
those patients who underwent the rubber hand illusion experience showed a decrease in size
estimation of the width of their own hands, decreasing their overestimation of body size (at least
peripherally). This is only one of a number of studies that provide hope for body-oriented
therapies for anorexia.
Body-Oriented Therapies for Anorexia

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Body-oriented therapies, or physiotherapies, are those that involve exercise, relaxation


training, body awareness therapy, yoga, massage, or any combination of these. They all use the
body as a way to access and alter the products of the mind: emotions and cognitions.
Vancampfort, Vanderlinden, and de Herts (2014) systematic review of physiotherapy for
anorexia nervosa and bulimia found that this form of treatment results in significant relief from
eating disorders and also significantly improves the quality of life of those experiencing eating
disorders but that it does not alter body fat or body mass index or reduce the depression or
anxiety that often accompanies these types of disorders. A similar paper by Vancampfort et al.
(2014) also found psychological benefits for individuals with anorexia or bulimia who
participated in physiotherapies that involve aerobic exercise, yoga, massage, or body awareness
therapy.
A number of other, less normative body-oriented types of therapies have also been
developed for or employed in the treatment of anorexia. One such Body Awareness Therapy
(BAT), evaluated by Wallin, Kronovall, and Majewski (2000), employs massage and
coordination exercises, among other approaches, in order to emphasize the boundary of the body.
Although Wallin et al.s (2000) study did not produce significant results, among the all-teenage
participants who were reassessed two years after the initial intervention, almost 90% of those
who received BAT on top of their normal therapy showed significant improvements in their
assessment of their own body measurements, while only approximately 20% of those who did
not receive BAT did. Another similar therapy, Basic Body Awareness Therapy, which combines
postural stability training, free breathing, mental awareness, and verbal reflection, has been
shown to decrease patients with anorexia and bulimias drive to thinness, body
dissatisfaction, and ineffectiveness (feelings of inadequacy, lack of control, etc.), as well as

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improving their overall attitude about their bodies and their mental health, although there is no
evidence that this particular therapy altered the participants perception of their body size
(Catalan-Matamoros, Helvik-Skjaerven, Labajos-Manzanares, Martnez-de-Salazar-Arboleas, &
Snchez-Guerrero, 2011). With an increasing emphasis on meditation and mindfulness in
psychology and society in general, it seems likely that investigation into body-oriented therapies
for anorexia and other disorders will continue to be tested. However, as of now, the findings on
the ability for such therapies to alter body size assessment in individuals with anorexia are
inconclusive. In addition to performing more studies in the area of exercise, yoga, meditation,
and awareness, other types of body-oriented therapies should also be explored.
Handwriting and Sense of Self in Space in Other Disorders
As noted above, there are a number of disorders aside from anorexia that involve a
distorted sense of body and/or self. Only in a very few of these disorders has instances of size
variability of handwriting been examined. In even fewer has any connection been made between
handwriting and ones sense of self in space.
Autism Spectrum Disorder (ASD). Simply observing the behavior of individuals with
autism reveals one common feature of the disorder: a tendency to violate the personal space of
others (Kennedy & Adolphs, 2014). This invasion of others personal space is likely attributable
to the fact that individuals with ASD appear to have a very tight, difficult to alter sense of
themselves in space, and because of this, they do not need to stand as far away from people in
order to differentiate themselves from others (Cascio et al., 2012).
Among the sparse articles written on the relationship between handwriting and ASD,
none as of yet seem to make the connection between the altered sense of personal space that is a
part of autism and macrographia (abnormally large handwriting), another frequent component of

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the disorder. One study by Beversdorf et al. (2001) suggested that macrographia could be a result
of motor coordination impairments in individuals on the spectrum. Another study, by Johnson et
al. (2013), also looked to a disruption of the motor control network (as well as the possibility of
delayed handwriting skills) as the cause of macrographia in individuals on the autism spectrum.
However, this was pure speculation, with none of the studies actually proving motor deficits to
be the definitive or singular cause of macrographia in those with autism. Abnormal sense of self
in space should also be considered as a possible explanation for this increased handwriting size.
If individuals with autism are not uncomfortable with invading the personal space of others
because their sense of the space around themselves, their peripersonal space, is more compact,
perhaps their larger handwriting is another means of expressing their tendency to ignore the
normal boundaries of space.
Parkinsons disease (PD). With Parkinsons disease, a degenerative disorder affecting
the central nervous system, sufferers may have an experience of peripersonal space that is
opposite of that of those with autism. Lee and Harris (1999) cited evidence that people with
Parkinsons disease have difficulty estimating gaps and moving through narrow spaces. Citing a
study by Sacks (1990), the researchers also referred to anecdotal evidence for some Parkinsons
sufferers experience of the outside world as fluid, with doorways appearing too small for them
to fit through. This suggests that those with Parkinsons disease might have much less rigid
peripersonal spaces than individuals with autism. At the same time, Lee and Harris (1999) noted
that, although Parkinsons patients difficulty with spatial skills may result from an alteration in
self-perception, it may actually just be the product of a change in the way patients perceive their
extrapersonal space. This returns to the question above about whether the distorted body image
of patients with anorexia comes from perceptual deficits or is more attitudinal in nature.

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As might be expected if those with Parkinsons disease have a more fluid, larger
peripersonal spaces, the disease often produces micrographia (exceptionally small handwriting)
in its sufferers. In fact, micrographia is frequently the earliest sign of Parkinsons (Ondo &
Satija, 2007; Sandyk, 1994). There is some evidence that this small handwriting can in part be
corrected for. Ondo and Satija (2007) were able to significantly increase the writing size of
Parkinsons disease patients simply by getting them to close their eyes while writing (suggesting
that micrographia in Parkinsons disease may be due, at least in part, to sensory-motor deficits).
Oliveira et al. (1997) also succeeded in helping Parkinsons disease sufferers increase their
handwriting size. They found that if patients with Parkinsons disease are forced to attend to their
writing either with visual cues (dots on paper that the participants must reach with their writing
instrument) or auditory cues (saying big repeatedly) their handwriting size could be
increased. Oliveira et al. (1997) also failed to investigate differences in peripersonal space as a
possible factor behind the small handwriting found in Parkinsons patients, so much research still
remains to be conducted in this area. However, the study did demonstrate that it is possible to get
individuals to alter their handwriting size, and such evidence provides encouraging support for
the possibility that other individuals experiencing micrographia, namely patients with anorexia,
may also be able to alter their handwriting.
Handwriting and Anorexia
Very little research exists in the area of anorexia and its effects on handwriting. Only one
study, a case study conducted by Sekar et al. (2010), is readily available. Sekar et al. (2010)
followed a 22-year-old female patient with anorexia, accompanied by micrographia and
hypophonia (low volume speech). The researchers considered the possibility that, because
anorexia is often associated with reduced social interaction (as part of conflict avoidance), the

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patients micrographia and hypophonia may have resulted from a desire to make herself smaller
in every way as to avoid conflict. Sekar et al. (2010) did not discuss any implications that the
link between anorexia and micrographia might have for adding to the knowledge base about
sense of self and body in anorexia nervosa. Future studies should examine why patients with
anorexia, who tend to overestimate the amount of space occupied by their bodies, produce such
small handwriting. Perhaps, because they perceive themselves to be larger than they actually are,
they feel a desire to shrink themselves, and handwriting is another way in which they can do so.
Embodiment and Signature Size
Ondo and Satija (2007) and Oliveira et al. (1997) are not the only ones to show that
techniques can be employed to force individuals to alter their handwriting size. In a very recent
study exploring how a sense of embodiment is reflected in signature size, Rawal, Harmer, Park,
OSullivan, and Williams (2014) were able to force their participants to increase their signature
size, using a number of methods. In the first phase of the experiment, implicit affective stimuli
increased the signature size of the participants. In a second phase, participants completed selffocus inductions that were either conceptual (thinking about reasons and implications or
experiential (sustained attention to sensory-perceptual features). Those in the experiential
condition had a significant increase in their signature size relative to those assigned to the
conceptual condition. This is consistent with the notion that processing stimuli in a way that
increases experiential self-focus increases signature size. Moving in a direction that will
hopefully pick up momentum in the coming years, Rawal et al. (2014) also included some
participants with anorexia nervosa in their signature size manipulation study. The anorexia
groups results did not differ from the non-anorexia group, but the former group, like the latter,
did experience increased signature size after receiving the treatment. This study shows that

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increased attention to embodiment does have the power to increase signature size, and, most
likely, handwriting more generally.
Future Directions
Handwriting and Other Disorders
There is still very little known about the relationship between handwriting size and
psychological and physical disorders that affect perception of the body and/or self. A simple
awareness of handwriting size variability among different disorders needs to be established
before exploring treatments that intend to alter the handwriting size of individuals suffering from
such illnesses.
Method 1.
Participants. One way to derive information about the handwriting size of individuals
suffering from different psychological illnesses is to use the evidence that already exists. In order
for an individual to be diagnosed with one of the disorders mentioned in the introduction to this
paper, he or she had to have sought the services of a mental health professional. This generally
requires the patient to fill out forms and/or sign documents, unless he or she is deemed incapable
of doing so. In addition, there are a number of individuals who participate in psychological
studies that are designed to acquire information about specific disorders. The handwriting of
study participants or those seeking mental health care would be very easy to study, as there is a
wealth of handwriting samples, and individuals are already classified according to disorder. It
would also be necessary to have a control group of individuals who do not suffer from any
psychological disorders, or at least not those known to interfere with perception of the body
and/or self.

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Procedure. Documents collected from study participants or patients in a mental health


setting would be examined and coded, using a consistent means of measurement. For example,
signature size (or word size, for that matter) can be measured by finding the total area covered by
the signature, calculated by multiplying the height (highest to lowest point) of the signature by its
length (beginning of first letter to end of last letter) (Rawal et al., 2014). Another potential way to
code handwriting size is to measure the size of one letter for example, the vertical length of the
letter l across handwriting samples (Oliveira et al., 1997).
Regardless of the operational definition of handwriting size that is ultimately decided
upon, an average handwriting size could be calculated for each disorder that is being examined.
Then, these averages could be compared, both to each other and to the control group made up of
individuals not known to suffer from distorted self-perception. If disorders that are known to
cause their sufferers to overestimate the amount of space their bodies occupy is correlated with
smaller handwriting than normal, and those disorders that cause their sufferers to underestimate
how much space they occupy is associated with larger handwriting, this may suggest that these
abnormalities in handwriting size derive from overcorrection of their sense of selves in space.
Method 2.
Participants. Another body of evidence that is readily available and accessible, if not
quite as readily, is writings produced by famous individuals. Relying on the writings of this
select group of people would not provide the largest variety in handwriting, but it would allow
for a comparison between the individuals handwriting pre-diagnosis and post-diagnosis, with the
participants serving as their own control group. Participants would be selected based on the
knowledge of their mental disorder (as stated on websites and verified more formally by
biographies), availability of a date of onset and/or diagnosis, and accessibility to their writings.

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Many famous people, especially those involved in the government or academia, have personal
paper collections, located at university or national libraries, which can generally be accessed by
researchers with ease. It may also be possible to find the autographs of famous people and
analyze them as well.
Procedure. This method of studying change in handwriting size would involve locating
eligible participants, going through their paper collections (or finding their autographs) from
around the time of their diagnoses, and measuring their handwriting to see if there are any
changes in size. If enough evidence can be gathered, it may also be possible to, as in Method 1,
take an average of the handwriting size of individuals with a specific disorder and compare this
average to the average handwriting size of people with a different disorder. This method of study
would have the same goals as Method 1 but would allow for a before-and-after picture of
handwriting size, which should increase confidence in the direction of the results by taking the
study from a correlational one to a natural experiment.
Effects of Forced Changed to Handwriting
Ondo and Satija (2007), Oliveira et al. (1997), and Rawal et al. (2014) have all already
shown that is possible to compel individuals to increase their handwriting size. However, a
number of questions about this process still exist. First of all, it is unclear how long the
observable effects of such interventions last, let alone if there are any benefits beyond the
physical increase in handwriting size. Additionally, given that the researchers all employed
different methods of getting their participants to increase their writing size, it is unclear which
method or methods are the most effective and long-lasting. A study needs to be devised that both
examines the potential psychological benefits of increasing ones handwriting size and
determines how to best cause this increase.

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Method.
Participants. Because the focus of this paper is on finding a treatment for anorexia
nervosa, the participants recruited for this study would be those who suffer from the disorder. An
ideal study would include a control group of those who do not have anorexia nervosa nor a
predisposition to it, those who may be at risk for anorexia because of the prevalence of the
disorder in their family or other predisposing factors but who do not yet suffer from the disorder,
those who have had anorexia for only a short while, those who have had it for a number of years
and are still struggling with the disorder, and those who are in the recovery phase and who may
or may not still exhibit micrographia. It is likely that not all of the recruited participants (perhaps
not even the majority) would suffer from micrographia, but this could actually be beneficial
because it would allow the researchers to examine the factors that may have caused the decrease
in handwriting size or, alternatively, protected against it.
Procedure. A complete history of the participants illness would be collected from them.
The participants would also be assessed on their current level of well-being, the number and
severity of any symptoms of anorexia they are currently experiencing, their current handwriting
size, and their current perception of their body size. As in Guardia et al.s (2010) study, this latter
measure could be collected by asking the participants to determine whether or not they would be
able to pass through apertures of varying sizes. All of these factors would need to be reassessed
after the treatment phase.
Before ever carrying out a more formal study, a trial phase should examine the
effectiveness of different methods of compelling individuals to increase their handwriting size.
The blindfolding employed by Ondo and Satija (2007) would probably have little effect on
anorexia, especially if body size misperception in anorexia derives from attitudinal differences

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rather than perceptual ones. Oliveira et al.s (1997) use of visual cues to increase handwriting
size may also have some merit for individuals suffering from anorexia, but using the same
auditory cues saying big repeatedly may actually make anorexia worse, as people with
anorexia may be at a risk of attributing this word to themselves. Rawal et al.s (2014) emphasis
on self-focus seems promising, but more research would need to be conducted in this area to see
how long-lasting the results are. An additional treatment method that could be explored includes
having the experimenter guide the participants hands and physically forcing them to write
bigger. Increase in handwriting size may also be made possible by providing clunky writing
instruments that only allow the participants the option of writing larger.
Once the most effective treatment (or several most effective treatments) is decided upon,
all of the different groups of participants can go through the treatment phase of the experiment.
Following treatment, the same measurements taken at the beginning of the study well-being,
presence of anorexia symptoms, handwriting size, and perception of body size will be taken
again. The post-treatment results will be compared to the pre-treatment measures, both within
individuals and between them. With all hope, not only will the treatment increase the
handwriting size of those experiencing micrographia, but it will relieve some of the symptoms of
anorexia and increase the overall well-being of those suffering from the disorder. By bringing
their handwriting size closer to normal size, perhaps individuals with anorexia can be convinced
that their bodies are closer to normal size than they had previously thought.
Conclusion
Much research still remains to be done in the area of psychological disorders and their
ability to distort their sufferers perception of their body size. The current research in the area,
especially those studies that have found body-oriented therapies to be effective, is very

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promising and provides hope that additional, perhaps disorder-specific, treatments could be
devised based on the same principles. This is truly a new realm of science that offers great hope
for the future. Only time will tell whether or not this current direction that research and treatment
is taking will find an important and lasting place in the world of psychology.

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