Letter

Child Study Center

volume 6 number 4 march / april 2002
education clinical care professional training scientific research school outreach information update

ADOLESCENTS AND BODY IMAGE:

Editors Comment
W h a t s T y p i c a l a n d W h a t s N o t
boys in the same age bracket reported Virginia, 12: "The best body is ribs, skin
Concern with body image the
overall dissatisfaction. These figures were and bones, and that's the only thing I care
internal personal picture boys and girls about."
much higher than those reported in previ-
have of their bodies can become a Karen, 15: "I'm fat and ugly. I have to
ous surveys conducted by the same maga-
major preoccupation during adolescence. lose twenty pounds. I need a nose job, my
zine in 1972 and 1985.1 Why are more
The perfect body as defined in the social hair is a mousy color; my lips are too thin
people becoming dissatisfied with their
culture can become a measure of self- appearance? The answer is certainly com- and I could use lip injections. I exercised
worth and can cause many teens to un- plex and influenced by a number of fac- my stomach muscles and now they're hard,
dervalue other abilities, interests and tors, including the growing disparity be- but I still have a belly."
talents. Adolescents must also deal with tween our actual body weights and those
developmental challenges such as adjust- of models, actors and celebrities depicted Historical Context
ing to hormonal and physical changes, as in advertising and the media. Although women in our society have al-
well as to new social and academic ways been concerned with appearance,
demands. Overemphasis on conforming standards of beauty have changed with the
to current standards of beauty renders
Body Image Defined
times. Thin was not always in. Prior to the
them vulnerable to developing psycholo- Body image is a person's inner con- 20th century, being thin was considered a
gical problems. ception of his or her own physical appea- sign of poverty, ill health and fragility. Plump-
rance. This conception may or may not ness was the ideal. Historian Joan Jacobs
In this issue of the NYU Child Study correlate with objective reality. Each Brumberg2 points to the differences be-
Center Letter, we discuss the meaning person holds an image of the physically tween past and present ideas of physical
and development of body image and dis- perfect person in mind and evaluates his or beauty. She writes, "in the twentieth cen-
tinguish normal dissatisfaction with ones her appearance against this ideal. A person tury, the body has become the central per-
body with more serious disorders. Al- who is pleased with his or her body shape sonal project of American girls." Brumberg
though no single cause for disturbances in and appearance is said to have a positive describes how the experience of living in an
body image has been pinpointed, an self-image. The psychological construct of adolescent body is shaped by the historical
body image includes cognitive and emo- moment. In the 1920s, adolescent females
array of risk factors biological,
tional aspects as well as sensory input. For made attempts to restrict calories and lower
psychological, familial and sociocultural their weight; this marked the first "dieting"
instance, we modify our ideas of our own
are involved. Treatment options are also period for American females. The "flapper
bodies according to our emotional state as
discussed. dress," with its emphasis on showing off
well as the reactions of others in the en-
AG/HSK vironment. the legs, set the stage for the throwing off of
corsets and subsequent restricted eating.
Much of the research on body image Brumberg chronicles the dieting frenzy of a
high school girl of that time: "I'm so tired
has been conducted on adolescents as
Introduction this developmental period is not only one
of being fat! I'm going back to school weigh-
Much has been written about body ing 119 pounds I swear it. Three months
of great physical change but also the time in which to lose thirty pounds but I'll do
image over the past decades almost all of that teens begin to subject themselves to it or die in the attempt." Brumberg also
it suggesting that both men and women (often painful) scrutiny. The changes of discusses how young girls' rising discontent
are growing increasingly dissatisfied with puberty and resulting sexual maturation with their appearance has reinforced a con-
their physical selves. The 1997 Psychology often make adolescents feel self-conscious sumer culture catering to these insecurities
Today Body Image Survey of 4,000 men and awkward about their bodies. throughout the 20th century. More recent-
and women asked participants about Adolescent girls appear to be particularly ly, the rise in popularity of blue jeans has
weight and attitudes towards their phy- vulnerable to developing a negative body paralleled females' insecurities about their
siques and specific body parts. Fifty-six image. They tend to ignore other abilities lower bodies specifically the thighs and but-
percent of women revealed that they were and focus on appearance as evidence of tocks. The recent surge in popularity of cell-
dissatisfied with their overall appearance, worthiness with consequent lowered ulite remedies has added fuel to the fire.
and an astounding 89% of women wanted self-esteem and increased risk for Many adolescent females are dating and
to lose weight. Fifty-four percent of girls psychiatric disorders, including eating sexually active at younger ages than before,
aged 13-19 were dissatisfied, and 41% of disorders. heightening concerns about appearance.
education clinical care professional training scientific research school outreach information update

SCHOOL OF
MEDICINE
How Self-Image Develops: out" creates a disparity between the
The Goodness-of-Fit Model cultural ideal of slimness and the actual
body type a massive "goodness of fit"
How do we develop an image of our
disparity. In general, boys in the study did
physical selves? Researcher Richard
not show an increase in dissatisfaction as
NEW YORK UNIVERSITY Lerner3 has proposed a paradigm called
they progressed in years; on the contrary,
Kenneth G. Langone "goodness of fit." He states that each per-
boys who were dissatisfied with their
Chairman, Foundation Board of Trustees son and his/her context are unique as a
height at age 13 felt more comfortable
Robert M. Glickman, M.D. result of the specific combination of the
with their height by age 15 reflecting the
Dean features of that person and the conditions
fact that many were well into their growth
NYU School of Medicine of his/her environment. Individuals elicit
reactions from others as a result of their spurt by this age. The authors conclude
physical (i.e., body build) and psychologi- that the increase in height and muscle
Editorial Board cal (i.e., behavior or temperament) chara- mass that boys experience in puberty,
cteristics. These reactions often feed back bringing them closer to a cultural ideal,
Harold S. Koplewicz, M.D., Founding Editor
to the individual, providing the basis for may be related to their body image
Arnold and Debbie Simon Professor of Child
further thought and action. Expectations improvement.
and Adolescent Psychiatry
Director of the Child Study Center are placed on a person as a result of the
New York University School of Medicine physical and/or social (i.e., parents, peers, How do adolescents' judgements of
media) components of a particular setting. their own appearance relate to judgements
Anita Gurian, Ph.D., Editor The individual's success in differentially by others? Which is a stronger predictor of
Executive Editor, www.AboutOurKids.org meeting these demands provides a basis for dissatisfaction and lowered self-esteem?
Clinical Assistant Professor the feedback he/she gets from the environ- These are complex questions. Using data
New York University School of Medicine ment. For instance, adolescents whose style from a large-scale study called the Pen-
of dress and hair meets parental approval nsylvania Early Adolescent Transition
might not simultaneously meet peer appro- Study (PEATS), researcher Richard
Howard Abikoff, Ph.D.
val, or vice-versa. Problems in adjustment Lerner5 and colleagues found that there
Pevaroff-Cohn Professor of Psychiatry
might develop as a result of mismatch, or was no significant relationship between
Director of Research
lack of goodness-of-fit, in either the peer or objective and subjective measures of at-
Child Study Center
parent context. The results of the present tractiveness, and also little relationship
New York University School of Medicine
author's work over 15 years, as well as that between objective ratings and individual
Robert Cancro, M.D. of other researchers in the field, support the adjustment. It was the adolescents' own
Professor and Chairman view that adolescents' physical characte- ratings of themselves that were correlated
Department of Psychiatry ristics provide a basis of their own body- with anxiety and self-worth. How we view
New York University School of Medicine image and psychosocial development by ourselves appears to be more important
Gabrielle A. Carlson, M.D. either fulfilling or not fulfilling the stereo- than how others see us.
Professor of Psychiatry and Pediatrics typical images of their social milieu.
New York State University at Stony Brook
Normative Discontent Distortions of Body Image
Stella Chess, M.D. Clearly, adolescent females who sub-
Professor of Child Psychiatry In the early adolescent and pre-teen
New York University School of Medicine years, girls whose bodies develop at a jectively distort their body image, or those
different pace than the average are for whom there is a mismatch between
Gail Furman, Ph.D.
especially prone to dissatisfaction and low their image and the environment, are at
Womens Commission on Refugee risk for several serious psychiatric dis-
Women and Children, United Nations self-esteem. Girls who are precociously
developed as well as those less well- orders. Chief among these are the eating
Glenn S. Hirsch, M.D. developed than peers are at risk. There disorders anorexia nervosa and bulimia
Assistant Professor of Clinical Psychiatry
have been very few studies examining nervosa. Anorexia nervosa, as defined in
Deputy Director, Child Study Center the Diagnostic and Statistical Manual of
Medical Director, Division of Child and adolescents' attitudes towards their bodies
Adolescent Psychiatry over time. However, in one such study,4 Mental Disorders, Fourth Edition (DSM
New York University School of Medicine the authors measured body image, IV) is an intense fear of gaining weight or
objective (rater) physical attractiveness becoming fat, even though underweight.6
Rachel Klein, Ph.D. Bulimia nervosa, felt to be a related dis-
Professor of Psychiatry and body mass index in the same 115 boys
New York University School of Medicine and girls at ages 13, 15, and 18. The order, is characterized by recurrent epi-
results were compelling; across the same sodes of binge eating followed by recur-
Maria Kovacs, Ph.D. rent inappropriate compensatory beha-
Professor of Psychiatry
period in adolescence, girls' body image
University of Pittsburgh School of Medicine worsened while boys' improved. At age vior (such as purging) in order to prevent
13, the differences between the sexes were weight gain. The pathophysiology of
Wade P. Parks, M.D., Ph.D. not dramatic, but the gap had widened these disorders, including a myriad of
Professor and Chairman possible causes, is a separate area of
Department of Pediatrics considerably by age 15. The authors point
New York University School of Medicine out that as a normal consequence of inquiry beyond the scope of the present
puberty, girls experience an increase in discussion. Most researchers and clini-
Alexander Thomas, M.D.
body mass with an accumulation of fat cians agree upon the fact that both of
Professor of Psychiatry these disorders involve disturbances of
New York University School of Medicine around the hips and thighs. This "filling
education clinical care professional training scientific research school outreach information update

perception, attitudes and behavior. Margaret, a 17 year old Caucasian Who is at Risk
Catherine Steiner-Adair7 sums up some of female, was housebound for three months. Over the past decades, the majority of
the research into the causes of eating Margaret repeatedly told her family that individuals with eating disorders have been
disorders, against a backdrop of female she was ashamed of multiple aspects of her young, female, white, and from middle to
adolescent development and societal appearance including her "big" nose, upper-class families in Western countries
values, as follows: "Girls who are able to "small" breasts, "flat" hair and "bad" and Japan. Girls with anorexia have
identify contemporary cultural values and skin. In reality, these deformities were traditionally been academically successful,
ideal images of women that are unsup- minimal or nonexistent. Margaret spent first or second-born children and often
portive of core female adolescent deve- several hours per day scrutinizing her work as dancers or athletes. They are said
lopmental needs and who are also able to appearance in the mirror and constantly to be compliant, approval-seeking, exces-
reject these values in choosing their own asked her family for reassurance that she sively dependent, perfectionistic and
female ideal image are not prone to eating looked okay. Her once-active social life socially anxious. Girls with bulimia, in
disorders. Girls who are unable to iden- dwindled down to nothing, as she contrast, tend to be more extroverted and
tify the societal values that are detrimen- routinely avoided dating and social more active interpersonally and socially. In
tal to their developmental needs, and who situations. Recently, she decided to begin the past decade, eating disorders have
identify with the ideal image that is consulting with plastic surgeons in order become more prevalent in the lower socio-
to improve her appearance. economic classes, among women over 25
projected by these values, are at risk for
developing eating disorders." Research years of age and among minority group
The etiology of BDD is unknown, but it members.11 The eating disorders often co-
into the biologic and genetic causes of
is felt to be a combination of biologic and exist with depression, anxiety and
eating disorders is presently being con-
environmental factors. Body Dysmorphic obsessive-compulsive disorder (OCD).
ducted, and it appears that certain in- Disorder is a serious psychiatric condition
dividuals have a biologic predisposition and can have disastrous consequences,
to develop these illnesses. In contrast to the eating disorders, Body
including suicide. At its core is a distur- Dysmorphic Disorder afflicts nearly equal
bance of body image so profound that the numbers of males and females and often
Both anorexia and bulimia can have preoccupation comes close to psychosis. co-exists with social anxiety, depression
serious medical, as well as psychiatric and OCD. Muscle dysmorphia, consi-
consequences. A teen with anorexia who dered a subset of BDD, affects males
is severely underweight may require
Vulnerability of Boys: The
almost exclusively and is associated with
hospitalization for malnutrition. Al- Case of Muscle Dysmorphia (but not necessarily caused by) low self-
though a teen with bulimia nervosa What about adolescent males? While esteem and mood and anxiety disorders.
might appear healthier than one with boys do not appear to suffer from body
anorexia, there are serious potential dissatisfaction with quite the same Treatments: The Eating
medical complications of bulimia inclu- frequency as girls, they are more at risk
than was previously realized. Boys are also
Disorders, BDD and Muscle
ding electrolyte imbalance as a result of
frequent vomiting, gastrointestinal as subject to the media representation of the Dysmorphia
well as dental problems, irregular heart- "ideal" male body in this case taut and The first step in seeking treatment for
beat and even cardiac arrest. bulging with muscles. The development these serious disorders is recognizing that
of males body image is affected by action the problem exists. As we know many, if
toys and an onslaught of images in the not most, adolescent girls want to lose
Body Dysmorphic Disorder: media glamorizing the muscular, fit body. weight. If an adolescent loses as much as
A recent study found that Playgirl center- 10 pounds, but appears to be eating in a
An Extreme Distortion folds have become more muscular over the healthy way, there is probably no cause for
Another psychiatric disorder that is magazine's 25 year history,9 reflecting our worry. However, if she seems obsessive,
associated with a disturbance of body cultural preoccupation with an ever more secretive or guilty about her eating, begins
image is Body Dysmorphic Disorder muscular male physique. Boys and men to have physical symptoms such as loss of
(BDD), formerly Dysmorphophobia. with extreme body dissatisfaction are at menstruation, or loses more than 10% of
This disorder has been described in the risk to develop a form of body dysmorphic her body weight, professional help should
world psychiatric literature for more than disorder known as muscle dysmorphia. be obtained. The first step is a thorough
a century, and has been studied sys- Previously termed reverse anorexia, medical evaluation by a pediatrician or
tematically in the United States since the muscle dysmorphia involves a preoccu- family practitioner to rule out any medical
mid-1990s. BDD, an intense preoccu- pation with the idea that one's body is not cause(s) of weight loss. The next step is a
pation with an imagined or slight defect sufficiently lean and muscular.10 The referral to a child and adolescent psychi-
in one's appearance, appears to have its thoughts are intrusive and associated with atrist for a complete psychiatric examina-
onset in adolescence or young adulthood a great deal of anxiety, and the activities tion. The most common treatments reco-
and often coexists with other psychiatric (i.e. weight lifting) can be so time- mmended are a combination of individual
conditions such as social anxiety consuming that school, work and social therapy, family therapy and nutritional
disorder, obsessive-compulsive disorder life are pushed aside. Muscle dysmorphia counseling. Psychotropic medication,
and atypical depression. In the largest involves a distortion in perception, where most commonly antidepressants, are often
study of DSM IV-defined BDD to date, the level of muscle mass is underestimated. prescribed, especially if there are co-
the mean age of onset was 16.4 +/- 6.9 Individuals with muscle dysmorphia are existing psychiatric conditions such as
years.8 The following is a typical case more likely to engage in such dangerous depression. Unlike the teen with anorexia,
history of an adolescent with BDD: behaviors as steroid use. the teen with bulimia is usually of normal
education clinical care professional training scientific research school outreach information update

weight or even slightly heavier. Thus, buli- target prevention efforts at the younger REFERENCES
mia can be harder to detect; adolescents age groups, as cases of anorexia in pre- 1. The 1997 Body Image Survey Results. Psychology
with bulimia tend to binge and purge in teenagers have increased. Today. Jan-Feb, 1997.
secret. Some clues might include: missing 2. Brumberg, JJ (1997) The Body Project. New
food, hoarding food, evidence of vomiting How Parents Can Help York: Random House.
and over-the-counter emetics and laxatives 3. Cash, T (Ed.) (1990) Body Images: Development,
What about those teens who have
in the household.12 If a teen is thought to Deviance and Change. New York: The Guilford
milder forms of body image distress? Press.
be binging and purging, professional help
Parents should:
should be sought. As with anorexia, 4. Rosenblum, GD & Lewis, M (1999) The
consultation with a child and adolescent relations among body image, physical
help adolescents realize that they are attractiveness and body mass in adolescence.
psychiatrist who is trained in the eva- Child Development. 70, 50-64.
valued because they are unique, not
luation and treatment of eating disorders
because of appearance or thinness, 5. Jovanovic J, Lerner, R & Lerner J (1989)
is a good first step. Commonly prescribed Objective and subjective attractiveness and early
treatments include individual psycho- accept their children's developing adolescent adjustment. Journal of Adolescence.
therapy, group therapy and/or family 12, 225-229.
sexuality and encourage open
therapy. As with anorexia, treatment with expression of feeling, 6. American Psychiatric Association (1994) Diag-
various psychotropic medications, most nostic and Statistical Manual of Mental Disorders,
Fourth Edition (DSM-IV). Washington, D.C.:
commonly antidepressants, can provide a discuss with their children the empha- American Psychiatric Press.
useful adjunct to therapy. sis that society places on appearance
7. Steiner Adair C., The body politic: Normal female
and encourage them to be critical of adolescent development and the development of
Treatment for Body Dysmorphic Disor- advertising claims and the media, eating disorders. Journal of the American Academy
der generally involves a combination of of Psychoanalysis. 14, 95-114.
pharmacotherapy and cognitive/behavi- praise their children's positive abilities 8. Phillips, KA, McElroy, SL, Hudson JI, Pope, HG
oral psychotherapy to correct underlying and talents, Jr. (1995) Body dysmorphic disorder: An OCD-
spectrum disorder, a form of affective spectrum
cognitive distortions. Treatment for disorder or both? Journal of Clinical Psychiatry.
monitor negative comments about
muscle dysmorphia has not been 56(suppl), 41-51.
their own bodies.
systematically studied, but the paradigms 9. Leit, RA (2001) The media's representation of the
used to treat BDD and the eating disorders ideal male body: A cause for muscle dysmorphia?
Summary Dissertation Abstracts International: Section B:
can provide a framework. In this case, the
Concerns about body image range from The Sciences and Engineering. 61 (8-B).
treatment of muscle dysmorphia would
a normal desire to look attractive to a 10.Olivardo, R (2001) Mirror, mirror on the wall,
involve a combination of psychoeducation,
pathological concern with thinness or who's the largest of them all? The features and
cognitive/behavioral therapy and possibly phenomenology of muscle dysmorphia. Harvard
physical perfection. Today, more than ever,
a serotonin-reuptake inhibitor (SSRI) if Review of Psychiatry. 9, 254-259.
adolescents in America are prone to body
depression or obsessions and compulsions
image distortions and dissatisfaction. The 11.Halmi, KA (1997) Models to conceptualize risk
are a prominent part of the disorder. factors for bulimia nervosa. Archives of General
reasons for this are multiple and include 1) Psychiatry. 54, 507-508.
a discrepancy between adolescents per-
How Schools Can Help ception of their own physical 12.Pruitt, DB (Ed.) (1999) American Academy of
Child and Adolescent Psychiatry: Your
characteristics and the expectations of Adolescent. New York: HarperResource.
Middle school efforts should:
their social environment, 2) the influence
focus on enhancing students aware- of the media and cultural expectations, RELATED ARTICLES
ness of their bodies by providing and 3) genetic and biological vulnerability.
About Body Dysmorphic Disorder
didactic material on natural body Adolescents with severe body image
AboutOurKids.org/articles/about_bdd.html
changes. The psychological and social distortions are vulnerable to developing
components of maturation (e.g., serious psychiatric disorders that can have About Eating Disorders
increased emotional arousal), relation- life-threatening consequences. Parents can AboutOurKids.org/articles/about_
ships with the opposite sex and issues help by providing guidance and infor- eating.html
with parents should be included, mation in a time of uncertainty and serving
as role models of individuals who are About Depressive Disorders
maintain a library of material on body comfortable with their bodies. AboutOurKids.org/articles/about_
image distortion and eating disorders depressive.html
as well as literature on nutrition,
ABOUT THE AUTHOR About Obsessive Compulsive Disorders
encourage discussions on sociocultural Naomi Weinshenker, M.D., Assistant AboutOurKids.org/articles/about_ocd.html
factors such as worship of thinness and Professor of Clinical Psychiatry at the
muscularity, NYU School of Medicine, is the Director Developing Healthy Eating Behaviors
AboutOurKids.org/articles/eatingtips.html
of the Young Adult Inpatient Program at
provide students with information Tisch Hospital and on the faculty of the
about the medical consequences of Mirror Mirror on the Wall: How to Raise
NYU Child Study Center. Her clinical and Girls with Healthy Self-Esteem
dieting, binging and purging. Many are research interests include Body Dysmor-
not aware of the serious physical conse- AboutOurKids.org/articles/mirror.html
phic Disorder, anxiety disorders and the
quences of using diuretics or laxatives, psychosocial aspects of obesity. She is a Seminal Issues in the Treatment of Eating
or other myriad dangers of an frequent contributor to print and tele- Disorders
extremely limited diet, vision media. AboutOurKids.org/articles/halmi.html