Introduction

Much has been written about body image over the past decades - almost all of it suggesting that both men and women are growing increasingly dissatisfied with their physical selves. The 1997 Psychology Today Body Image Survey of 4,000 men and women asked participants about weight and attitudes towards their physiques and specific body parts. Fifty-six percent of women revealed that they were dissatisfied with their overall appearance, and an astounding 89% of women wanted to lose weight. Fifty-four percent of girls aged 13-19 were dissatisfied, and 41% of boys in the same age bracket reported overall dissatisfaction. These figures were much higher than those reported in previous surveys conducted by the same magazine in 1972 and 1985.1 Why are more people becoming dissatisfied with their appearance? The answer is certainly complex and influenced by a number of factors, including the growing disparity between our actual body weights and those of models, actors and celebrities depicted in advertising and the media.

Body Image Defined

Body image is a person's inner conception of his or her own physical appearance. This conception may or may not correlate with objective reality. Each person holds an image of the physically perfect person in mind and evaluates his or her appearance against this ideal. A person who is pleased with his or her body shape and appearance is said to have a positive self-image. The psychological construct of body image includes cognitive and emotional aspects as well as sensory input. For instance, we modify our ideas of our own bodies according to our emotional state as well as the reactions of others in the environment.

Much of the research on body image has been conducted on adolescents as this developmental period is not only one of great physical change but also the time that teens begin to subject themselves to (often painful) scrutiny. The changes of puberty and resulting sexual maturation often make adolescents feel self-conscious and awkward about their bodies. Adolescent girls appear to be particularly vulnerable to developing a negative body image. They tend to ignore other abilities and focus on appearance as evidence of worthiness - with consequent lowered self-esteem and increased risk for psychiatric disorders, including eating disorders.

Virginia, 12: "The best body is ribs, skin and bones, and that's the only thing I care about."

Karen, 15: "I'm fat and ugly. I have to lose twenty pounds. I need a nose job, my hair is a mousy color; my lips are too thin and I could use lip injections. I exercised my stomach muscles and now they're hard, but I still have a belly."

Historical Context

Although women in our society have always been concerned with appearance, standards of beauty have changed with the times. Thin was not always in. Prior to the 20th century, being thin was considered a sign of poverty, ill health and fragility. Plumpness was the ideal. Historian Joan Jacobs Brumberg2 points to the differences between past and present ideas of physical beauty. She writes, "in the twentieth century, the body has become the central personal project of American girls." Brumberg describes how the experience of living in an adolescent body is shaped by the historical moment. In the 1920s, adolescent females made attempts to restrict calories and lower their weight; this marked the first "dieting" period for American females. The "flapper dress," with its emphasis on showing off the legs, set the stage for the throwing off of corsets and subsequent restricted eating. Brumberg chronicles the dieting frenzy of a high school girl of that time: "I'm so tired of being fat! I'm going back to school weighing 119 pounds - I swear it. Three months in which to lose thirty pounds - but I'll do it - or die in the attempt." Brumberg also discusses how young girls' rising discontent with their appearance has reinforced a consumer culture catering to these insecurities throughout the 20th century. More recently, the rise in popularity of blue jeans has paralleled females' insecurities about their lower bodies - specifically the thighs and buttocks. The recent surge in popularity of cellulite remedies has added fuel to the fire. Many adolescent females are dating and sexually active at younger ages than before, heightening concerns about appearance.

How Self-Image Develops: The Goodness-of-Fit Model

How do we develop an image of our physical selves? Researcher Richard Lerner3 has proposed a paradigm called "goodness of fit." He states that each person and his/her context are unique as a result of the specific combination of the features of that person and the conditions of his/her environment. Individuals elicit reactions from others as a result of their physical (i.e., body build) and psychological (i.e., behavior or temperament) characteristics. These reactions often feed back to the individual, providing the basis for further thought and action. Expectations are placed on a person as a result of the physical and/or social (i.e., parents, peers, media) components of a particular setting. The individual's success in differentially meeting these demands provides a basis for the feedback he/she gets from the environment. For instance, adolescents whose style of dress and hair meets parental approval might not simultaneously meet peer approval, or vice-versa. Problems in adjustment might develop as a result of mismatch, or lack of goodness-of-fit, in either the peer or parent context. The results of the present author's work over 15 years, as well as that of other researchers in the field, support the view that adolescents' physical characteristics provide a basis of their own bodyimage and psychosocial development by either fulfilling or not fulfilling the stereotypical images of their social milieu.

Normative Discontent

In the early adolescent and pre-teen years, girls whose bodies develop at a different pace than the average are especially prone to dissatisfaction and low self-esteem. Girls who are precociously developed as well as those less welldeveloped than peers are at risk. There have been very few studies examining adolescents' attitudes towards their bodies over time. However, in one such study,4 the authors measured body image, objective (rater) physical attractiveness and body mass index in the same 115 boys and girls at ages 13, 15, and 18. The results were compelling; across the same period in adolescence, girls' body image worsened while boys' improved. At age 13, the differences between the sexes were not dramatic, but the gap had widened considerably by age 15. The authors point out that as a normal consequence of puberty, girls experience an increase in body mass with an accumulation of fat around the hips and thighs. This "filling out" creates a disparity between the cultural ideal of slimness and the actual body type - a massive "goodness of fit" disparity. In general, boys in the study did not show an increase in dissatisfaction as they progressed in years; on the contrary, boys who were dissatisfied with their height at age 13 felt more comfortable with their height by age 15 - reflecting the fact that many were well into their growth spurt by this age. The authors conclude that the increase in height and muscle mass that boys experience in puberty, bringing them closer to a cultural ideal, may be related to their body image improvement.

How do adolescents' judgements of their own appearance relate to judgements by others? Which is a stronger predictor of dissatisfaction and lowered self-esteem? These are complex questions. Using data from a large-scale study called the Pennsylvania Early Adolescent Transition Study (PEATS), researcher Richard Lerner5 and colleagues found that there was no significant relationship between objective and subjective measures of attractiveness, and also little relationship between objective ratings and individual adjustment. It was the adolescents' own ratings of themselves that were correlated with anxiety and self-worth. How we view ourselves appears to be more important than how others see us.

Distortions of Body Image

Clearly, adolescent females who subjectively distort their body image, or those for whom there is a mismatch between their image and the environment, are at risk for several serious psychiatric disorders. Chief among these are the eating disorders - anorexia nervosa and bulimia nervosa. Anorexia nervosa, as defined in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM IV) is an intense fear of gaining weight or becoming fat, even though underweight. Bulimia nervosa, felt to be a related disorder, is characterized by recurrent episodes of binge eating followed by recurrent inappropriate compensatory behavior (such as purging) in order to prevent weight gain. The pathophysiology of these disorders, including a myriad of possible causes, is a separate area of inquiry beyond the scope of the present discussion. Most researchers and clinicians agree upon the fact that both of these disorders involve disturbances of perception, attitudes and behavior. Catherine Steiner-Adair sums up some of the research into the causes of eating disorders, against a backdrop of female adolescent development and societal values, as follows: "Girls who are able to identify contemporary cultural values and ideal images of women that are unsupportive of core female adolescent developmental needs and who are also able to reject these values in choosing their own female ideal image are not prone to eating disorders. Girls who are unable to identify the societal values that are detrimental to their developmental needs, and who identify with the ideal image that is projected by these values, are at risk for developing eating disorders." Research into the biologic and genetic causes of eating disorders is presently being conducted, and it appears that certain individuals have a biologic predisposition to develop these illnesses.

Both anorexia and bulimia can have serious medical, as well as psychiatric consequences. A teen with anorexia who is severely underweight may require hospitalization for malnutrition. Although a teen with bulimia nervosa might appear healthier than one with anorexia, there are serious potential medical complications of bulimia including electrolyte imbalance as a result of frequent vomiting, gastrointestinal as well as dental problems, irregular heartbeat and even cardiac arrest.

Body Dysmorphic Disorder: An Extreme Distortion

Another psychiatric disorder that is associated with a disturbance of body image is Body Dysmorphic Disorder (BDD), formerly Dysmorphophobia. This disorder has been described in the world psychiatric literature for more than a century, and has been studied systematically in the United States since the mid-1990s. BDD, an intense preoccupation with an imagined or slight defect in one's appearance, appears to have its onset in adolescence or young adulthood and often coexists with other psychiatric conditions such as social anxiety disorder, obsessive-compulsive disorder and atypical depression. In the largest study of DSM IV-defined BDD to date, the mean age of onset was 16.4 +/- 6.9 years.8 The following is a typical case history of an adolescent with BDD:

Margaret, a 17 year old Caucasian female, was housebound for three months. Margaret repeatedly told her family that she was ashamed of multiple aspects of her appearance including her "big" nose, "small" breasts, "flat" hair and "bad" skin. In reality, these deformities were minimal or nonexistent. Margaret spent several hours per day scrutinizing her appearance in the mirror and constantly asked her family for reassurance that she looked okay. Her once-active social life dwindled down to nothing, as she routinely avoided dating and social situations. Recently, she decided to begin consulting with plastic surgeons in order to improve her appearance.

The etiology of BDD is unknown, but it is felt to be a combination of biologic and environmental factors. Body Dysmorphic Disorder is a serious psychiatric condition and can have disastrous consequences, including suicide. At its core is a disturbance of body image so profound that the preoccupation comes close to psychosis.

Vulnerability of Boys: The Case of Muscle Dysmorphia

What about adolescent males? While boys do not appear to suffer from body dissatisfaction with quite the same frequency as girls, they are more at risk than was previously realized. Boys are also subject to the media representation of the "ideal" male body - in this case taut and bulging with muscles. The development of males' body image is affected by action toys and an onslaught of images in the media glamorizing the muscular, fit body. A recent study found that Playgirl centerfolds have become more muscular over the magazine's 25 year history,9 reflecting our cultural preoccupation with an ever more muscular male physique. Boys and men with extreme body dissatisfaction are at risk to develop a form of body dysmorphic disorder known as muscle dysmorphia. Previously termed "reverse anorexia," muscle dysmorphia involves a preoccupation with the idea that one's body is not sufficiently lean and muscular.10 The thoughts are intrusive and associated with a great deal of anxiety, and the activities (i.e. weight lifting) can be so timeconsuming that school, work and social life are pushed aside. Muscle dysmorphia involves a distortion in perception, where the level of muscle mass is underestimated. Individuals with muscle dysmorphia are more likely to engage in such dangerous behaviors as steroid use.

Who is at Risk

Over the past decades, the majority of individuals with eating disorders have been young, female, white, and from middle to upper-class families in Western countries and Japan. Girls with anorexia have traditionally been academically successful, first or second-born children and often work as dancers or athletes. They are said to be compliant, approval-seeking, excessively dependent, perfectionistic and socially anxious. Girls with bulimia, in contrast, tend to be more extroverted and more active interpersonally and socially. In the past decade, eating disorders have become more prevalent in the lower socioeconomic classes, among women over 25 years of age and among minority group members.11 The eating disorders often coexist with depression, anxiety and obsessive-compulsive disorder (OCD).

In contrast to the eating disorders, Body Dysmorphic Disorder afflicts nearly equal numbers of males and females and often co-exists with social anxiety, depression and OCD. Muscle dysmorphia, considered a subset of BDD, affects males almost exclusively and is associated with (but not necessarily caused by) low selfesteem and mood and anxiety disorders.

Treatments: The Eating Disorders, BDD and Muscle Dysmorphia

The first step in seeking treatment for these serious disorders is recognizing that the problem exists. As we know many, if not most, adolescent girls want to lose weight. If an adolescent loses as much as 10 pounds, but appears to be eating in a healthy way, there is probably no cause for worry. However, if she seems obsessive, secretive or guilty about her eating, begins to have physical symptoms such as loss of menstruation, or loses more than 10% of her body weight, professional help should be obtained. The first step is a thorough medical evaluation by a pediatrician or family practitioner to rule out any medical cause(s) of weight loss. The next step is a referral to a child and adolescent psychiatrist for a complete psychiatric examination. The most common treatments recommended are a combination of individual therapy, family therapy and nutritional counseling. Psychotropic medication, most commonly antidepressants, are often prescribed, especially if there are coexisting psychiatric conditions such as depression. Unlike the teen with anorexia, the teen with bulimia is usually of normal weight or even slightly heavier. Thus, bulimia can be harder to detect; adolescents with bulimia tend to binge and purge in secret. Some clues might include: missing food, hoarding food, evidence of vomiting and over-the-counter emetics and laxatives in the household.12 If a teen is thought to be binging and purging, professional help should be sought. As with anorexia, consultation with a child and adolescent psychiatrist who is trained in the evaluation and treatment of eating disorders is a good first step. Commonly prescribed treatments include individual psychotherapy, group therapy and/or family therapy. As with anorexia, treatment with various psychotropic medications, most commonly antidepressants, can provide a useful adjunct to therapy.

Treatment for Body Dysmorphic Disorder generally involves a combination of pharmacotherapy and cognitive/behavioral psychotherapy to correct underlying cognitive distortions. Treatment for muscle dysmorphia has not been systematically studied, but the paradigms used to treat BDD and the eating disorders can provide a framework. In this case, the treatment of muscle dysmorphia would involve a combination of psychoeducation, cognitive/behavioral therapy and possibly a serotonin-reuptake inhibitor (SSRI) if depression or obsessions and compulsions are a prominent part of the disorder.

How Schools Can Help

Middle school efforts should:

  • focus on enhancing students' awareness of their bodies by providing didactic material on natural body changes. The psychological and social components of maturation (e.g., increased emotional arousal), relationships with the opposite sex and issues with parents should be included,
  • maintain a library of material on body image distortion and eating disorders as well as literature on nutrition,
  • encourage discussions on sociocultural factors such as worship of thinness and muscularity,
  • provide students with information about the medical consequences of dieting, binging and purging. Many are not aware of the serious physical consequences of using diuretics or laxatives, or other myriad dangers of an extremely limited diet,
  • target prevention efforts at the younger age groups, as cases of anorexia in preteenagers have increased.

How Parents Can Help

What about those teens who have milder forms of body image distress? Parents should:

  • help adolescents realize that they are valued because they are unique, not because of appearance or thinness,
  • accept their children's developing sexuality and encourage open expression of feeling,
  • discuss with their children the emphasis that society places on appearance and encourage them to be critical of advertising claims and the media,
  • praise their children's positive abilities and talents,
  • monitor negative comments about their own bodies.

Summary

Concerns about body image range from a normal desire to look attractive to a pathological concern with thinness or physical perfection. Today, more than ever, adolescents in America are prone to body image distortions and dissatisfaction. The reasons for this are multiple and include 1) a discrepancy between adolescents' perception of their own physical characteristics and the expectations of their social environment, 2) the influence of the media and cultural expectations, and 3) genetic and biological vulnerability. Adolescents with severe body image distortions are vulnerable to developing serious psychiatric disorders that can have life-threatening consequences. Parents can help by providing guidance and information in a time of uncertainty and serving as role models of individuals who are comfortable with

About the Author

Naomi Weinshenker, M.D., Assistant Professor of Clinical Psychiatry at the NYU School of Medicine, is the Director of the Young Adult Inpatient Program at Tisch Hospital and on the faculty of the NYU Child Study Center. Her clinical and research interests include Body Dysmorphic Disorder, anxiety disorders and the psychosocial aspects of obesity. She is a frequent contributor to print and television media.

References
  1. The 1997 Body Image Survey Results. Psychology Today. Jan-Feb, 1997.
  2. Brumberg, JJ (1997) The Body Project. New York: Random House.
  3. Cash, T (Ed.) (1990) Body Images: Development, Deviance and Change. New York: The Guilford Press.
  4. Rosenblum, GD & Lewis, M (1999) The relations among body image, physical attractiveness and body mass in adolescence. Child Development. 70, 50-64.
  5. Jovanovic J, Lerner, R & Lerner J (1989) Objective and subjective attractiveness and early adolescent adjustment. Journal of Adolescence. 12, 225-229.
  6. American Psychiatric Association (1994) Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). Washington, D.C.: American Psychiatric Press.
  7. Steiner Adair C., The body politic: Normal female adolescent development and the development of eating disorders. Journal of the American Academy of Psychoanalysis. 14, 95-114.
  8. Phillips, KA, McElroy, SL, Hudson JI, Pope, HG Jr. (1995) Body dysmorphic disorder: An OCDspectrum disorder, a form of affective spectrum disorder or both? Journal of Clinical Psychiatry. 56(suppl), 41-51.
  9. Leit, RA (2001) The media's representation of the ideal male body: A cause for muscle dysmorphia? Dissertation Abstracts International: Section B: The Sciences and Engineering. 61 (8-B).
  10. Olivardo, R (2001) Mirror, mirror on the wall, who's the largest of them all? The features and phenomenology of muscle dysmorphia. Harvard Review of Psychiatry. 9, 254-259.
  11. Halmi, KA (1997) Models to conceptualize risk factors for bulimia nervosa. Archives of General Psychiatry. 54, 507-508.
  12. Pruitt, DB (Ed.) (1999) American Academy of Child and Adolescent Psychiatry: Your Adolescent. New York: HarperResource.