Letter
Child Study Center
volume 6 number 4
education clinical care professional training scientific research school outreach information update
Editors Comment
Concern with body image the
internal personal picture boys and girls
have of their bodies can become a
major preoccupation during adolescence.
The perfect body as defined in the social
culture can become a measure of self-
worth and can cause many teens to un-
dervalue other abilities, interests and
talents. Adolescents must also deal with
developmental challenges such as adjust-
ing to hormonal and physical changes, as
well as to new social and academic
demands. Overemphasis on conforming
to current standards of beauty renders
them vulnerable to developing psycholo-
gical problems.
In this issue of the NYU Child Study
Center Letter, we discuss the meaning
and development of body image and dis-
tinguish normal dissatisfaction with ones
body with more serious disorders. Al-
though no single cause for disturbances in
body image has been pinpointed, an
array of risk factors biological,
psychological, familial and sociocultural
are involved. Treatment options are also
discussed.
AG/HSK
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 phy-
siques 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
march / april 2002
ADOLESCENTS AND BODY IMAGE:
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
overall dissatisfaction. These figures were
much higher than those reported in previ-
ous surveys conducted by the same maga-
zine in 1972 and 1985.1 Why are more
hair is a mousy color; my lips are too thin
people becoming dissatisfied with their
appearance? The answer is certainly com-
plex and influenced by a number of fac-
tors, including the growing disparity be-
tween 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 con-
ception of his or her own physical appea-
rance. 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 emo-
tional 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 en-
vironment.
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
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 al-
ways 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. Plump-
ness was the ideal. Historian Joan Jacobs
Brumberg2 points to the differences be-
tween past and present ideas of physical
beauty. She writes, "in the twentieth cen-
tury, the body has become the central per-
sonal 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 weigh-
ing 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 con-
sumer culture catering to these insecurities
throughout the 20th century. More recent-
ly, the rise in popularity of blue jeans has
paralleled females' insecurities about their
lower bodies specifically the thighs and but-
tocks. The recent surge in popularity of cell-
ulite remedies has added fuel to the fire.
Many adolescent females are dating and
sexually active at younger ages than before,
heightening concerns about appearance.
education clinical care professional training scientific research school outreach information update
SCHOOL OF
MEDICINE
NEW YORK UNIVERSITY
Kenneth G. Langone
Chairman, Foundation Board of Trustees
Robert M. Glickman, M.D.
Dean
NYU School of Medicine
Editorial Board
Harold S. Koplewicz, M.D., Founding Editor
Arnold and Debbie Simon Professor of Child
and Adolescent Psychiatry
Director of the Child Study Center
New York University School of Medicine
Anita Gurian, Ph.D., Editor
Executive Editor, www.AboutOurKids.org
Clinical Assistant Professor
New York University School of Medicine
Howard Abikoff, Ph.D.
Pevaroff-Cohn Professor of Psychiatry
Director of Research
Child Study Center
New York University School of Medicine
Robert Cancro, M.D.
Professor and Chairman
Department of Psychiatry
New York University School of Medicine
Gabrielle A. Carlson, M.D.
Professor of Psychiatry and Pediatrics
New York State University at Stony Brook
Stella Chess, M.D.
Professor of Child Psychiatry
New York University School of Medicine
Gail Furman, Ph.D.
Womens Commission on Refugee
Women and Children, United Nations
Glenn S. Hirsch, M.D.
Assistant Professor of Clinical Psychiatry
Deputy Director, Child Study Center
Medical Director, Division of Child and
Adolescent Psychiatry
New York University School of Medicine
Rachel Klein, Ph.D.
Professor of Psychiatry
New York University School of Medicine
Maria Kovacs, Ph.D.
Professor of Psychiatry
University of Pittsburgh School of Medicine
Wade P. Parks, M.D., Ph.D.
Professor and Chairman
Department of Pediatrics
New York University School of Medicine
Alexander Thomas, M.D.
Professor of Psychiatry
New York University School of Medicine
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 per-
son 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 psychologi-
cal (i.e., behavior or temperament) chara-
cteristics. 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 environ-
ment. For instance, adolescents whose style
of dress and hair meets parental approval
might not simultaneously meet peer appro-
val, 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 characte-
ristics provide a basis of their own body-
image and psychosocial development by
either fulfilling or not fulfilling the stereo-
typical 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
risk for several serious psychiatric dis-
self-esteem. Girls who are precociously
developed as well as those less well-
developed 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 Pen-
nsylvania Early Adolescent Transition
Study (PEATS), researcher Richard
Lerner5 and colleagues found that there
was no significant relationship between
objective and subjective measures of at-
tractiveness, 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 sub-
jectively distort their body image, or those
for whom there is a mismatch between
their image and the environment, are at
orders. 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.6
Bulimia nervosa, felt to be a related dis-
order, is characterized by recurrent epi-
sodes of binge eating followed by recur-
rent inappropriate compensatory beha-
vior (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 clini-
cians agree upon the fact that both of
these disorders involve disturbances of
education clinical care professional training scientific research school outreach information update
perception, attitudes and behavior.
Catherine Steiner-Adair7 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 unsup-
portive of core female adolescent deve-
lopmental 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 iden-
tify the societal values that are detrimen-
tal 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 con-
ducted, and it appears that certain in-
dividuals 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. Al-
though a teen with bulimia nervosa
might appear healthier than one with
anorexia, there are serious potential
medical complications of bulimia inclu-
ding electrolyte imbalance as a result of
frequent vomiting, gastrointestinal as
well as dental problems, irregular heart-
beat 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 sys-
tematically in the United States since the
mid-1990s. BDD, an intense preoccu-
pation 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 distur-
bance 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 center-
folds 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 preoccu-
pation 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 time-
consuming 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, exces-
sively 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 socio-
economic classes, among women over 25
years of age and among minority group
members.11 The eating disorders often co-
exist 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, consi-
dered a subset of BDD, affects males
almost exclusively and is associated with
(but not necessarily caused by) low self-
esteem 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 psychi-
atrist for a complete psychiatric examina-
tion. The most common treatments reco-
mmended are a combination of individual
therapy, family therapy and nutritional
counseling. Psychotropic medication,
most commonly antidepressants, are often
prescribed, especially if there are co-
existing psychiatric conditions such as
depression. Unlike the teen with anorexia,
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-
mia 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 eva-
luation and treatment of eating disorders
is a good first step. Commonly prescribed
treatments include individual psycho-
therapy, 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 Disor-
der generally involves a combination of
pharmacotherapy and cognitive/behavi-
oral 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 aware-
ness of their bodies by providing
didactic material on natural body
changes. The psychological and social
components of maturation (e.g.,
increased emotional arousal), relation-
ships 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 conse-
quences 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 pre-
teenagers 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 empha-
sis 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 per-
ception 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 infor-
mation in a time of uncertainty and serving
as role models of individuals who are
comfortable with their bodies.
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 Dysmor-
phic Disorder, anxiety disorders and the
psychosocial aspects of obesity. She is a
frequent contributor to print and tele-
vision 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) Diag-
nostic 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 OCD-
spectrum 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
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11.Halmi, KA (1997) Models to conceptualize risk
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12.Pruitt, DB (Ed.) (1999) American Academy of
Child and Adolescent Psychiatry: Your
Adolescent. New York: HarperResource.
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