Introduction

Body image is the subjective picture of individuals of their own body, irrespective of how their body actually looks.[1][2] Body image is a complex construct comprising thoughts, feelings, evaluations, and behaviors related to one’s body.[3] Body image misperception is common in the general population and is also a core component of several serious diseases, including body dysmorphic disorder, anorexia nervosa, and bulimia nervosa.[4][5] Distortions in body image are unpleasant and can have tragic results.[6] Poor body image can affect physical and psychological health and can influence self-esteem, mood, competence, social functioning, and occupational functioning. The understanding of the neurotypical distortions in healthy cognition and perceptual distortions in clinical conditions is essential to address body image concerns and enable suffering individuals to lead more contented and productive lives.[4] In this activity, we outline the role of body image in psychological and physical functioning and describe features of various body image-related conditions and disorders.

Historical Perspective

Early in the 1900s, there were considerable efforts by neurologists to understand unusual forms of body perception reported by patients with brain injury, or phantom limb experience in amputees. The early concepts of body image indeed were rooted in neuropathology. Head, in 1920, first defined body image as a unity of past experiences created in the cerebral sensory cortex. Schilder, who was a neurologist, proposed a biopsychosocial approach to body image, highlighting the need to examine its neurological, psychological, and sociocultural components. Newell noted that body image is dynamic and changes with age, mood, or even clothing. Krueger suggested that body image is the representation of identity derived from both external and internal body experiences.[7]

Definition

What is body image, and why is it important?

Body image is one of the components of personal identity. Body image is the figure that one has on their anthropometric measurements, contours, and shape of the body; and also the feelings correlated to these factors that affect the satisfaction with the body or specific parts of the body.[8] Indeed, body image represents how we think, feel, perceive, and behave regarding our bodies.[9]

Body image is a multidimensional concept. The complexity of body image can be appreciated by looking at its components. These components apply to people with healthy and unhealthy perceptions of their bodies and include:

• Cognitive: thoughts and beliefs about the body
• Perceptual: how people perceive the size and shape of their body and body parts
• Affective: feelings about the body
• Behavioral: the actions that people perform to check on, tend to, alter, or conceal their body[9]

Related but different terms are often used interchangeably in the literature concerning the state of consciousness in which there is an altered body image perception, including body image distortion, body image misperception, body image disturbance, negative body image, altered body image, and body dissatisfaction. The problem of variable terms is intensified by the fact that some studies focus on psychiatric or medical patients, some deal with nonpatients, and others deal with both groups.

Body image distortion is a multidimensional symptom, comprising various components of body image. Components that most widely accepted are the cognitive, the perceptive, and the affective. The cognitive component is from thoughts and beliefs concerning body shape and appearance, and the mental representation of the body. The perceptive component involves the identification and estimation of the body, and it indicates the accuracy of the individuals' evaluation of their body size, shape, and weight compared to their actual proportions. Finally, the affective component includes feelings that individuals develop towards their body and satisfaction or dissatisfaction of individuals about their body.[5]

Thereupon, body image disturbance can manifest as disturbance of percept (i.e., distortion) and concept (i.e., body dissatisfaction). Perceptual disturbance involves the failure to evaluate the size of one’s body accurately. Body dissatisfaction includes attitudinal or affective perception of one’s body and negative feelings and cognitions. Body image disturbances are thought to also manifest on a behavioral level, such as body avoidance, body checking, or dieting.[10]

Negative body image characteristically demonstrates a dissatisfaction of body or body parts, preoccupation with appearance, and engaging in behaviors such as frequent mirror checking, self-weighing, or avoidance of public situations. Negative body image often gets measured as body dissatisfaction.[3] Body dissatisfaction is attributable to a discrepancy between the perception of body image and its idealized image.[8]

Body Image Development

There are some debates as to when body image development begins.

Price believes that primitive sense of body image originates in the uterus with spontaneous movements of the fetus and corresponding feedback from sensory and proprioceptive input. Body image is a learned phenomenon from experiences during both pre-natal and post-natal development in which cross-cortical connections and mirror neurons play prominent roles.[11] Complex interactions between neurophysiological, socio-cultural, and cognitive factors contribute to body image development and maintenance.[6] Different factors such as gender, fashion, peer groups, educational and familial influences, evolving socialization, and physical alterations (hair growth, acne, breast development, menstruation) put children into unknown territory with vulnerable body images.[7]

Primary socialization takes place early in life, and a sense of self-recognition is assumed to develop by the age of two. Children in the toddler years become aware of their gender. They also discover social norms, such as competitiveness and athleticism for men (strong legs, muscles, large arms), and beauty or smallness for females (glossy hair, perfect skin, tiny waist, no hips). When children become aware of their body appearance, they attempt to manipulate their parents to receive admiration and approval. This need for approval grows upon starting school, exhibiting a need for social acceptance. Cash assumes body image as a learned behavior. Smolak proposes that children mainly focus on appearance in the context of the toys they play with, such as Barbie dolls. As children grow and socialize, they begin comparing themselves with other children, especially concerning appearance (e.g., little children desire to be bigger). By the age of 6, body shape becomes increasingly prominent consideration (especially muscle and weight). Smolak reported that among school children aged 6 to 12 years old, 40–50% demonstrated dissatisfaction with some part of their body size or shape.[7]

Adolescence indicates the transition from childhood to adulthood and is associated with physical and social changes.[7] Adolescence is a critical period in body image development. Body image in adolescents is also under the influence of parents. The parent-adolescent relationship has a significant impact on the development of adolescents’ body dissatisfaction. Parents send sociocultural or critical messages and messages about body appearance ideals to their children. When Individuals feel secure regarding their relationships, they are more satisfied with their body and less likely to think in ways that they have to adhere to appearance ideals to receive others’ acceptance. Researches have shown that adolescents with better parent-adolescent relationships are less likely to experience body dissatisfaction.[12] Although in younger children, the influence of families on body image development is more significant than friends, the role of parents decreases as children get older and peer responses become more important than families. Body image in people aged 14 to 27 is greatly affected by their peers.[7] A critical event or series of events such as teasing and rejection may lead to body image misperception. Studies have found that the more frequent being teased about body size and weight while growing up, the more likely to experience body image distortion and body dissatisfaction during adulthood.[13]

Etiology

Body image distortion is central to several serious diseases, including eating disorders and body dysmorphic disorder. Although the former assumption was that body image in healthy individuals is highly accurate, recent researches have shown that systematic distortions of body representation are also a normal part of healthy cognitive life. These distortions in healthy people might indicate weak forms of body image distortions seen in various diseases. Understanding of these neurotypical distortions may help to understand the perceptual distortions in clinical settings.[4]

Body image is the term that predominantly implies a visual representation of body shape and size, similar to a 2D photograph that shows what we look like as a physical object and how other people see us from the outside. However, besides our ability to assess the body as if viewed from the outside, we are also able to perceive it from the inside. This internal way of body image perception is obviously unavailable for other physical objects, and it provides us with additional sources of information, including touch, proprioception, and interoception. While most of both behavioral and functional neuroimaging studies have primarily concentrated on body misperception/dissatisfaction as a unisensory concept related to the visual domain, new studies have pointed that the combination of the visual and somatosensory body representations affect the perceptual assessment of body image.[4] Research has found that basic interoceptive processes (the sensations generated by internal organs) and interoceptive awareness may significantly contribute to the formation of body image.[14] Furthermore, different manifestations of body image distortion are observable in patients with anorexia nervosa including reduced interoceptive awareness, overestimation of tactile stimuli; abnormal body scaled action, disturbed haptic perception, and altered integration of proprioceptive and visual information. In general, body image perception is a multisensory concept that includes different inputs such as visual, tactile, proprioceptive, and interoceptive. Hence, the perception of one's own body is due to co-perception and combination of the different sensory information. In general, body image perception is a multisensory concept that includes different inputs such as visual, tactile, proprioceptive, and interoceptive. Hence, the perception of one's own body is due to co-perception and combination of the different sensory information.[5][14]

Additionally, biased information processing may contribute to the misperception of body size and shape. Memory biases, attentional biases, and interpretation biases are different kinds of cognitive biases that have been found to be partly responsible for the distorted body image in individuals with eating disorders.

Memory biases refer to the facilitated/impaired encoding and remembering of disorder salient information such as words or sentences related to weight and shape, compared to neutral information.

Attentional biases include three components of attention:

1-Facilitated attentional capture: disorder salient information is detected faster than non-salient information.

2- Difficulty in disengagement: disorder salient information is more difficult to disengage, e.g., stronger attention towards unattractive parts of one’s own body compared to attractive parts.

3- Attentional avoidance: keeping attention away from disorder salient information.

Interpretation biases refer to the biased information-processing and tendency to inappropriately analyze ambiguous information, e.g., everyday scenarios, according to disorder-specific cognitive schemata.[10]

One particularly interesting point is that recent studies have found links between body image distortions in healthy individuals and homuncular distortions in primary somatosensory cortex (SI). Research has shown that healthy individuals tend to overestimate their body part in length while underestimating them in volume. This pattern of body representation shows some resemblance to a well-known depiction of a somatosensory homunculus.[4]

Moreover, body dissatisfaction and body image distortions in patients with anorexia nervosa appear to have links to the parietal lobe function. Neuroimaging studies have found sub-optimal visual and tactile performance in anorexia nervosa that suggests indirect associations of body image distortion with parietal lobe dysfunction.[4]

Factors Affecting Body Image and Body Image Disorders

To date, various factors that influence body image have been studied such as BMI, family, peers, society, media, culture, self-esteem, psychopathology, gender, age, marital status, education level, smoking status, alcohol consumption, physical activity, weight control behavior, religiosity, and spirituality.[1][15] Since body dissatisfaction is detrimental to wellbeing, it is essential to identify its correlates.

• Body Mass Index (BMI)

One of the most important factors influencing body image and body satisfaction is BMI, a continuous variable using the standard formula of kilograms over height squared. As a biological component, BMI has been found to contribute to body image and fear of negative evaluation (fear that one will be evaluated unfavorably because of one’s appearance). Overweight individuals are more likely to report the sense of fear associated with being negatively evaluated while engaging in social situations compare to their normal-weight counterparts. They also tend to show negative affective attitudes toward their body.[16] Body image discordance is the discrepancy between body image and BMI and defined as perceived body size minus actual body size. Underestimation is perceiving the body as smaller than the actual BMI, and overestimation is perceiving the body as larger than the actual BMI. body image discordance is associated with body image dissatisfaction and negatively impacts mental health, including lowering self-esteem and increasing depression.[15]

• Family

Family plays an important role in the development of children’s body image, body size attitudes, and eating patterns, as they form in early childhood. Family is a prominent and continuing influence, as children develop the need for parental admiration and approval. Parents may increase or decrease the risk of the development of body image and eating concerns in their children, directly or indirectly. Parents with particular attention toward weight control behaviors have significant influences on children’s body satisfaction. Direct parental attitudes can include commenting to a child about their weight or appearance, teasing about a child’s weight, pressuring a child to lose weight, or encouraging a child to diet. Indirect parental behaviors are actions or attitudes that are not necessarily planned to influence the child, including parents’ negative comments about their bodies and parental engagement in excessive exercise or dieting. These behaviors may model self-criticism and inspire children to judge themselves or others based on appearance and highlight the importance of adhering to social and cultural body size ideals. Some other family features may also contribute to body satisfaction, such as the socioeconomic status of the family and living in large cities.[1][17]

• Social Pressures

Although body image is a mental concept, it is observable as a social phenomenon. Both women and men attempt to present and maintain themselves in socially desirable body shape. Social acceptance is a critical component of the lifecycle and is central to well being. In response to the need for social acceptance, individuals develop behavioral responses that enhance their social desirability. Through the social learning process, individuals observe, imitate, and reinforce their behavior to increase the likelihood of social acceptance; this is particularly important in adolescents for attaining acceptance in peer groups.[1][15] Weight-related bullying during adolescence significantly contributes to the development of negative body perceptions and body dissatisfaction. The pressure to lose weight or gain muscle that adolescents experience from society is associated with body dissatisfaction.[18]

• Media

Children and adolescents today grow up in a world flooded with different types of mass media such as television, movies, videos, billboards, magazines, music, newspapers, and the internet. Newer forms of media (e.g., internet, social media, computer games) is being more popular than traditional forms (e.g., printed materials and TV) as time goes on. Several studies suggest a link between the muscular male body ideal and the thin female beauty ideal represented in the media with a variety of psychological conditions including body image misperception, body dissatisfaction, and eating disorders. This link has been explained mostly by sociocognitive processes such as social comparison.[19]

• Social Media

Social media is a more recent form of media that has become increasingly popular worldwide, and nowadays, messages regarding appearance ideals delivered through social media. Due to its continuous availability (e.g., on smartphones), the influences of social media may be more potent than traditional forms of media. Several studies have suggested that active social media engagement may negatively influence body image and appears to be associated with body dissatisfaction and eating disorders. Different theoretical mechanisms have been proposed, such as body appearance comparisons and self-objectification.[20] On social media, users post their photographs and view photos of others, and physical appearance is an important factor in these activities. In addition to receiving messages and comments about their bodies on social media, users see carefully edited and selected social media imagery including depictions of thin bodies (thinspiration) or lean and muscular bodies (fitspiration). Users might frequently compare themselves with appearance ideals that conveyed to them through social media and internalize these ideals as the standards for their own body. When their physical appearance is not a match for the internalized ideals, this may result in body dissatisfaction. This concept is particularly important in adolescents who spend more time and receive more feedback about their appearance on social media.[21]

• Self-esteem

Body image is highly related to an individual’s self-esteem and self-concept. Self-esteem can be a potential factor reducing the adverse association of BMI, body image, and fear of negative evaluation. Higher self-esteem may serve as a protective factor, decreasing the negative association between BMI and feelings of individuals about their body, also reducing the level of anxiety caused by others’ unfavorable judgments.[16] Furthermore, Body dissatisfaction is negatively associated with self-esteem and is a strong predictor of self-esteem reduction, particularly in adolescents. This association is not equal for all adolescents, and it may be more influential in racial, ethnic, or gender groups that pay more attention to appearance and body shape.[1][22]

• Other Factors

Chronic illnesses may have a negative influence on the self-concept. The social stigma due to serious illnesses such as endocrine disorders and cancers can affect self-esteem and body image.[23]

Many studies have investigated the association between experiences of abuse and body image concerns. Physical and sexual abuse strongly influences the physical and mental health of victims. Research has demonstrated that such abuse is associated with more severe symptoms of depression, more negative body image and low self-esteem, and a higher propensity for eating disorders.[24]

Depression and obesity are public health problems that have a bidirectional association, and both can affect the perception of body image and improve or complicate comorbid clinical conditions. Individuals with depression tend to distort their body image negatively, while those with obesity are generally more dissatisfied with their body.[8]

Early reports indicates that social distancing and other lockdown measures associated with the COVID-19 pandemic have been associated with an increase in maladaptive eating habits and body dissatisfaction, particularly, in certain groups with a current or past diagnosis of eating disorders.[25]

Epidemiology

Body image has been a focus in many research studies from various aspects such as body image perception and body satisfaction. Both body image distortion and body image dissatisfaction are global and are considered related. Findings of the prevalence of body dissatisfaction vary considerably, depending on several factors, including the population studied, geographical location, assessment scale, and questionnaire used to measure this construct.[1]

Body satisfaction differs in different age and gender groups. Studies observe the highest levels of body dissatisfaction in adolescence, early adulthood, and women. In general, the rate of body image misperception has been reported up to 50%, and the reported rate of body dissatisfaction is between 30% and 75%.[1][21] Based on cross-sectional studies, the prevalence of body image dissatisfaction can be as high as 71% among adolescents. A 24-country, cross-sectional survey of children in school-age has indicated that body dissatisfaction is highly prevalent and is more common among girls than boys, among older adolescents than younger adolescents, and overweight than non-overweight. Other cross-sectional surveys from the United States, Canada, Europe, Pakistan, Korea, and China indicate that approximately 45% of children and adolescents experience body image-related concerns.[26][27]

The prevalence of body dissatisfaction in children and adolescents of developed countries varies between 35% and 81% in girls and from 16% to 55% in boys. Studies reveal that 40 to 70% of uninjured adolescent girls are unhappy with at least two features of their bodies, with 50 to 80% stating that they desire to be thinner.[7][26] Body image distortion is less common in young adults than in teenagers. Younger adults tend to overestimate their body size. 25% of male and 45% of female college students overestimate their body.[15] In general, women perceive their body heavier and larger than it actually is, likely due to the idealization of a thin ideal body.[8] Men tend to undervalue their body size, likely due to the idealization of a muscular and larger body.[8][15][18] Adolescent girls aspire to become thinner, and adolescent boys tend to desire athletic body shape.[26]

There are also differences among ethnic groups. African American women typically report less body image dissatisfaction compared with White women. Body image dissatisfaction across other ethnic groups appears to be related to the level of acculturation.

History and Physical

Distortions of the body image are critical characteristics of eating disorders and body dysmorphic disorder.[4] Sometimes, merely asking an individual about his or her world view (e.g., optimistic, pessimistic, attractive, confident, insecure, or unappealing) will begin the dialogue between caregiver and patient regarding body image. Fortunately, several quantifiable measures are available for body image assessment in children, adolescents, and adults which will be discussed further in the following section. Since each age group faces different developmental tasks, each needs a different measure.[23]

Eating Disorders

Patients with eating disorders are often afraid to be judged or criticized. These fears are more notable as it reports repeatedly show that attitudes of health professionals towards eating disorders patients are not always positive. Training and support strategies may minimize these effects.[28] Clinicians have access to numerous standardized self-report measures and interview-based measures. There have always been debates about the superiority of clinical interviews as opposed to self-report measures; however, the choice depends on the purpose and context of assessment, time limitations, and availability of training and clinical factors.[29]

Administration of standardized self-report questionnaires is quick and easy. In primary care situations, where an eating disorder is suspected, shorter measures such as the Eating Attitudes Test and SCOFF are more useful. Longer self-report measures such as Eating Disorder Inventory (EDI-3) are more useful in specialist settings to collect precise information about the severity and the extent of psychopathology. Clinical interviews are more time-consuming, require training, are often considered as gold standards, and are more likely useful for research purposes compared to clinical settings.[29]

Body Dysmorphic Disorder

Questions that can be asked to diagnose body dysmorphic disorder (BDD) include[30]:

• Are you unhappy with your appearance in any way?
• What don’t you like about your appearance? OR What is your concern?
• Are you unhappy with any other aspects of your appearance, such as your face, hair, skin, nose, or the size or shape of any other body area?
• Approximately what amount of time do you spend per day thinking about your appearance if you were to add up all the time you spend?
• How much distress do these appearance concerns cause you?
• Do these appearance concerns interfere with your life or cause difficulties for you in any way?

It is essential to ask precisely what body areas the patient is concerned with and what body area is the most pressing concern, instead of assuming which ones they are. This approach is particularly important because some patients may have actual appearance flaws without significant concern and suggesting that these areas appear defective can undermine the therapeutic relationship and upset the patient. Moreover, some patients are too embarrassed to share all of their appearance concerns. These patients require to meet with the clinician numerous times to feel more comfortable. Patients who are depressed, socially anxious or anxious, housebound, abusing substances, or suicidal should have screening for BDD.[30]

When interviewing a patient to diagnose BDD, the clinician’s attitude is very important. Questions about appearance concerns need to be in a rational and empathic way. All concerns need to be taken seriously and not considered vanity. Many of these patients are rejection sensitive and unwilling to reveal their concerns since they are fearful that they others will see them as superficial or vain. BDD is a serious disease, and these patients suffer tremendously and can be highly suicidal.[30]

When attempting to diagnose BDD, it is easy to make mistakes and miss the diagnosis. It is recommended to avoid certain types of questions. A clinician should avoid asking if the patient is concerned with an imagined defect. The word “imagined” is problematic based on the fact that most BDD patients tend to have poor insight and consider their problem to be real. Another question to avoid is asking if the patient believes he or she is disfigured or deformed. Instead, the clinician can guide the patient by asking, “What words do you use to describe your appearance? Some people would say they look ugly, unattractive, or even deformed. Do any of these words describe how you see yourself?” Also, a clinician should not ask if patients think there is something wrong with their body. This question is general, and it is better to ask precisely about appearance concerns.[30]

Although by definition, the appearance defects are minimal or nonexistent, the patient’s appearance can provide clues to the presence of BDD. For instance:[30]

• Picking the skin or having noticeable skin lesions or scarring
• Wearing heavy or unusual makeup
• Wearing a hat all the time
• Covering the face with hand or hair
• Wearing big or bulky clothes to cover body or body parts
• Always having a tan
• Wearing sunglasses even on cloudy days
• Excessive hair plucking (e.g., unusually thin eyebrows), unusual hairstyles or hairpieces
• Excessive plastic surgeries

Evaluation

Body image involves two independent modalities[4]:

1. A attitudinal component: the feelings that an individual has about their body size and shape
2. A perceptual component: the accuracy with which an individual can judge the dimensions of their body or body parts

Measuring the Attitudinal Component

Assessment of the attitudinal component of body image has been more straight-forward than the perceptual component. Body dissatisfaction is the most frequently measured attitudinal component of body image. Commonly, psychometric tools are used to evaluate body dissatisfaction. Although a variety of techniques are available for the assessment of body dissatisfaction, figure rating scales have been the most commonly used tool. This type of scale typically includes a set of figures that vary in body size from being very underweight to very overweight. Participants are asked to choose a figure that represents their perceived actual body size, and also the figure that they would like to be (i.e., the ideal body size). The discrepancy between an individual’s perceptual and ideal body image represents body dissatisfaction. Fortunately, several quantifiable measures are available for body image assessment in children, adolescents, and adult.[23]

Some measurements available for assessment of the attitudinal component of body image in children[23]:

• Kid’s Eating Disorders Survey
• Body Image Assessment Procedure for Children's (BIA-C)
• Body Image Scale
• body-esteem questionnaire

 Some measurements available for assessment of the attitudinal component of body image in adolescents and adults[23]:

• Contour Drawing Rating Scale: a type of figure rating scale comprises of nine sub-figures. The participant is required to choose sub-figures that represents their current, ideal, and healthy body size.
• Multidimensional Body-Self Relations Questionnaire (MBSRQ): A validated; 69 item inventory consists of 10 subscales that assess multiple aspects of body image.
• Body Image Assessment (BIA): this is a type of figure rating scale comprised of nine sub-figures.
• Somatomorphic matrix (a computerized test)
• Body esteem scale
• Body-esteem scale for adolescents and adults
• Body-Image Ideals Questionnaire (BIQ)
• Self-Image Questionnaire for Young Adolescents (SIQYA)
• Attention to Body Shape Scale (ABS)

Measuring the Perceptual Component

Assessment of the perceptual component of body image has been more challenging than the attitudinal component. To date, several methods have been developed that classified into two general groups.[4]

1- Depictive methods: the participant compares their own body to a visual or a 2D image, and include tasks such as[4]:

• The distorting mirror
• The distorted photograph technique
• Video distortion
• Template matching

2- Metric methods: the participant compares their own body to a physical length or a 1D standard, and include tasks such as:[4]

• the moving caliper
• the image marking procedure
• the adjustable light beam apparatus

Computer Generated Imagery (CGI) is a new technology that has been used to generate standard stimuli and personalized 3D avatars that reflect changes in body shape based on BMI.[6]

Other Useful Measures

Eating Disorder Inventory (EDI-3) is also helpful to assess body image. Three subscales of the EDI-3 are especially important for measuring body image. The body dissatisfaction subscale, the drive for thinness subscale, and the interoceptive awareness subscale.

Several other useful inventories available for clinical work include the body areas satisfaction test, the wishing well test, the distressing situations test, the body image thoughts test, and the body/self-relationship test.

Treatment / Management

Several interventions have been developed to improve body image.

General Cognitive-behavioral Techniques

Cognitive-behavioral therapy (CBT) is the most commonly used and most empirically supported intervention to improve body image. CBT aims to target core cognitive and behavioral processes that contribute to negative body image, and helps individuals to modify their dysfunctional thoughts, feelings, and behaviors related to their body image.[2] 

Examples of techniques[2]:

• Discuss cognitions and the role they play in body image
• Teach self-monitoring and restructuring of cognitions
• Teach self-monitoring of behavior
• Change negative body language
• Conduct guided imagery
• Conduct exposure exercises
• Write about the body
• Provide relapse-prevention strategies
• Provide stress management training

Techniques to Enhance Physical Fitness

Fitness training interventions comprise aerobic or anaerobic exercises for enhancing physical capacities such as muscular strength, and also for encouraging individuals to focus more on the functionality and less on the appearance.[2] 

Techniques to Provide Media Literacy and to Promote Media Resistance

Media literacy interventions aim to teach individuals to critically evaluate the appearance ideals that conveyed to them by the media. Examples of techniques[2]:

• Discuss the beauty ideal
• Provide media literacy training

Techniques to Enhance Self-esteem

Self-esteem enhancing interventions have been found beneficial, safe, and suitable for improving body image. Examples of techniques[2]:

• Discuss alternatives to focus on appearance
• Discuss interpersonal relations
• Discuss individual differences

Techniques Providing Psychoeducation Related to Body Image

Psychoeducation aims to educate individuals about body image concept, negative body image, and its causes and consequences. Psychoeducation is often useful along with other interventions, such as fitness training interventions or self-esteem enhancement. Examples of techniques[2]:

• Discuss the causes of negative body image
• Discuss the consequences of negative body image
• Discuss the concept of body image
• Discuss the behavioral expression of negative body image

Cognitive Remediation Therapy (CRT)

Research into body image has begun to look at the neuropsychological aspects of how an individual with body image disturbance cognitively process information. Cognitive Remediation Therapy (CRT) or Cognitive Enhancement Therapy is a group of interventions that are designed to enhance an individual’s neurocognitive abilities such as cognitive flexibility and planning, attention, working memory, set-shifting, and executive functioning. CRT can identify and target the cognitive impairments specific to an individual.[31]

Pharmacotherapy in Body Dysmorphic Disorder

Current clinical guidelines indicate that cognitive-behavioral therapy (CBT) plus serotonin-reuptake inhibitors (SRIs) are the first-line treatments for body dysmorphic disorder. Appropriate pharmacotherapy improves core BDD symptoms, suicidality, and psychosocial functioning in a majority of patients. The patient’s willingness to accept and adhere to pharmacotherapy requires identification since many patients have poor insight and may desire cosmetic treatment instead of pharmacotherapy. The doses of SRI medication necessary to treat BDD are often higher than doses needed to address other common psychiatric disorders, and patients should remain on the medication for relatively long periods.[32]

Pharmacotherapy in Eating Disorders

Several drugs have been targets of study in anorexia nervosa treatment, including selective serotonin reuptake inhibitors, antidepressants, antipsychotics, nutritional supplementation, and hormonal medications. There is limited evidence supporting pharmacotherapy in anorexia nervosa, and many patients do not respond to the available treatments. In general, drugs are useful for patients with bulimia nervosa (BN) and binge eating disorder (BED). Antidepressants are the primary pharmacotherapy in bulimia nervosa. For binge eating disorder, Lisdexamphetamin is the first medication to be approved by the FDA for the treatment of binge eating disorder.[33]

Differential Diagnosis

Normal Appearance Concern

Body image falls on a continuum from healthy body perceptions to unhealthy body perceptions. Accordingly, body dysmorphic disorder concerns may be on a spectrum with normal appearance concerns, contrasting only quantitatively. Appearance concerns are increasingly common. Ongoing studies in the United States indicate that the number of people who experience dissatisfaction with some aspect of their physical appearance is progressively increasing. At the same time, an increasing interest exists for cosmetic specialists and procedures to enhance physical appearance.[34]

Dysmorphic Concern

Dysmorphic concern is attributable to an excessive concern and preoccupation with a perceived or slight defect in the body, also includes concerns about body odor or function and non-appearance related somatic concerns. Dysmorphic concerns also lie on a continuum of severity from no or minimal concerns to severe concerns. Dysmorphic concern is not a DSM diagnosis.[35]

Disordered Eating

The definition of disordered eating attitudes is any abnormal thoughts, beliefs, affects, and behaviors towards food, and are associated with body image misperception, body dissatisfaction, and unhealthy weight control beliefs and practice. It is important to note that eating problems exist on a spectrum from disordered eating that does not meet the DSM criteria to anorexia nervosa and bulimia nervosa. Disordered eating is a risk factor for the development of full-syndrome eating disorders, and thus, early detection to provide appropriate intervention is particularly important.[36]

Anorexia Nervosa (AN)

Eating disorders (ED) are among the most severe manifestations of body image dysfunction. Traditionally, treatment of eating disorders involves the treatment of body image disturbances. Body image distortion is a core characteristic of anorexia nervosa (AN), and this distortion exists in both attitudinal and perceptual level. Anorexia nervosa is the restriction of energy intake, body image distortion and misperception of body weight, fear of gaining weight or becoming fat, and significantly low BMI. In the DSM-5, the amenorrhea criterion no longer applies for anorexia nervosa. AN has a prevalence of 0.4% and is considered to be one of the most challenging psychiatric disorders to treat with the highest mortality rates in mental disorders.[5][37]

Bulimia Nervosa (BN)

Bulimia nervosa (BN) is a potentially life-threatening and debilitating eating disorder characterized by recurrent episodes of overeating (bingeing) followed by inappropriate compensatory behaviors (purging) such as self-induced vomiting, misusing of laxatives or diuretics, and excessive exercise, to compensate for the excessive caloric intake. Body image distortion often accompanies bulimia nervosa and excessive concern about body weight and shape. Indeed, Self-evaluation and self-worth in these individuals suffer undue influence from body shape and weight. BN has a chronic or intermittent course and often persists for several years after onset.[38][39]

Body Dysmorphic Disorder (BDD)

The fifth edition of the Diagnostic and Statistical Manual of Mental disorders-5 (DSM-5) characterizes body dysmorphic disorder as a distressing preoccupation or a markedly excessive concern with one or more perceived or slight defects in physical appearance, associated with significant distress and functional impairment. The criteria also specify that at some point during the illness, individuals perform repetitive and compulsive behaviors in response to their appearance concerns. These irresistible and distressful compulsions can be behavioral (e.g., mirror checking, excessive grooming, camouflaging, skin picking, reassurance seeking) or mental acts (e.g., comparing the disliked appearance features to those of other people). A majority of patients exhibit excessive self-consciousness, often with ideas or delusions of reference, which are irrational beliefs that random incidents in the world relate directly to them. For instance, thinking that others are taking special notice of, talking about, judging, or mocking them because of the perceived defect or flaw.[40] As in anorexia and bulimia nervosa, body image disturbances precede the disease.[23] It is important to note that, if an eating disorder explains all patient’s appearance concerns, an eating disorder is a more appropriate diagnosis than BDD.[30]

BDD is associated with significant psychosocial impairment and high rates of depression, suicidality, and hospitalization. Estimates of the prevalence of BDD in the general population are between 0.7% and 3.2%. BDD is frequently found in clinical settings, with prevalence of 13% to 16% in psychiatric inpatients, 4.8% in adolescent inpatients, 9% to 12% in dermatology settings, 8% to 37% in individuals with OCD, 3% to 53% in cosmetic surgery settings, 11% to 13% in social phobia, and 14% to 42% in atypical major depressive disorder.[41]

Muscle Dysmorphia (MD)

Muscle dysmorphia is a rare form of body dysmorphic disorder that is focused on muscularity and mostly found in men. It refers to an extreme desire to gain lean muscle mass and preoccupation with a perceived lack of muscularity. Although muscle dysmorphia is included in DSM-5 as a variant of body dysmorphic disorder, similarities with eating disorders, particularly anorexia nervosa, have been postulated. Researchers have proposed that MD is a reverse form of anorexia nervosa and even the word “bigorexia” has been coined to explain it. Individuals with MD may experience impairment in social and occupational functioning because of embarrassment over their perceived appearance flaws and consequently, their tendency for social withdrawal; also because of their need to follow a careful diet and time-consuming workout schedule. They may also damage their health by risky body change behaviors, excessively working out, and use of anabolic-androgenic steroids.[42]

Binge Eating Disorder (BED)

 DSM-5 characterizes binge eating disorder as recurrent episodes of consuming large amounts of food (i.e., binge eating), quickly and until feeling uncomfortably full. Additional criteria include eating alone, eating without being hungry, feeling guilty, disgusted, or depressed after overeating, marked distress regarding binge eating, and absence of regular compensatory behaviors such as purging. Although the criteria for BED do not include a body image related criterion, new evidence show that body image disturbance might play roles in BED and could be a target for treatment.[10]

Obsessive-compulsive Disorder (OCD)

Obsessive-compulsive disorder is a disabling condition characterized by obsessions and compulsions. Recent studies have shown that OCD may be associated with different aspects of body image. In addition to OCD, several other disorders have key obsessive and compulsive characteristics. In BDD, the obsessive thoughts direct on their perceived defect and how they can resolve the physical problem. Further, the compulsive behaviors include checking their appearance, temporary solutions such as camouflaging, or the search for permanent solutions.[43]

Social Anxiety Disorder (SAD)

Recent studies have suggested that social anxiety disorder may be associated with body image-related dysfunction. Social anxiety disorder and BDD are two different but conceptually overlapping disorders. Individuals who do not necessarily have BDD but perceive themselves being unattractive tend to have more social anxiety.[43]

Major Depressive Disorder

Patients with major depressive disorder experience alteration in posture and dissatisfaction with body image during episodes of depression.

Generalized Anxiety Disorder (GAD)

Deliberate Self-harm (DSH)

Trichotillomania

Prognosis

• Studies about the course and outcome of eating disorders have generally noted that approximately 50% of patients do well with time, approximately 30% improve but continue to have symptoms, and approximately 20% remain unwell. The prognosis in adolescents is moderately better than adults, particularly with a longer duration of follow-up.[44]

• Medical morbidity and mortality associated with the starvation state in eating disorders are significant risks in affected individuals.[44]

• Eating disorders represent the highest mortality rate of adolescents among all other psychiatric conditions.[38]

• Eating disorders are associated with increased suicide risk and self-harming behaviors.[38]

• Both anorexia nervosa and bulimia nervosa are characterized by a serious course and outcome in many of the affected individuals.[45]

• Moderating factors of the outcome in AN and BN include the onset of the disease during adolescence and longer duration of follow-up. Unfavorable prognostic factors include chronicity, vomiting, bulimia, and purgative abuse, and obsessive-compulsive features.[45]

• Anorexia nervosa is associated with poor prognosis. Treatment of AN is challenging, no medication has been approved for its treatment, and it often persists after treatment.[14]

• For females at age 15 to 24, anorexia nervosa has a mortality rate 12 times higher than the all other causes of death.[46]

• AN has the highest risk of mortality among all other psychiatric disorders.[46]

• The long-term outcome of BN is slightly better than AN; however, the mortality rate is low.[45]

• Individuals with BDD are less apt to be married, more likely to be divorced, and more likely to be unemployed compared to the general population.[41]

• Treatment of BDD is challenging due to the poor insight associated with BDD. Patients are generally unwilling to adhere to the treatment, particularly in the presence of comorbidities such as suicidality and depressive symptoms.[47]

• To decrease the likelihood of relapse following symptom remission, patients with BDD should remain on medication for a relatively long time.[47]

• BDD is a chronic disorder that requires long-term therapy. Pharmacotherapy and CBT-derived interventions have proven beneficial in the treatment of BDD; however, a significant number of patients remain unresponsive to therapy.[47]

• Approximately 80% of patients with body dysmorphic disorder report past or current suicidal ideation, 24 to 28% attempt suicide during their lifetime and the suicide-related mortality rate is approximately 0.3% per year.

Complications

Reports in the scientific literature have found a correlation between body image disturbance and several mental and physical health outcomes.

• Evidence consistently shows that unhealthy body image is associated with obesity and physical inactivity.[38]

• Patients that overestimate their body size may practice unhealthy weight control methods such as skipping meals, self-induced vomiting, fasting, and taking unprescribed weight-loss pills. The nutrition imbalance and extreme calorie restriction due to unhealthy weight control behaviors can lead to temporary weight loss, anemia, osteoporosis, irregular menstruation, amenorrhea, and dehydration.[38]

• Studies consistently have shown a significant association between negative body image and depression. Body dissatisfaction and body image misperception can become even more severe in the presence of depression.[8]

• Body image attitudes are affected by specific life context and quality of life. Body dissatisfaction may have negative outcomes, including anxiety or feeling stressful, poor self-esteem, isolation, preoccupation with appearance, and social anxiety.[1][2]

• Individuals with body image disturbance may attempt dramatically to alter their appearance, for example, through seeking cosmetic surgeries. Steroid abuse and excessive gym attendance to increase muscle mass are common in patients with muscle dysmorphia.[1][6]

• Body image misperception could be an important indicator of self- injurious behaviors and suicidal behaviors.[38]

• Negative body image is associated with impaired sexual functioning and sexual dissatisfaction. Research shows that body dissatisfaction increases the risk of sexual dissatisfaction in women.[2]

• Negative body image is associated with unsafe health behaviors such as unsafe sexual practices, smoking, and skin cancer risk behaviors.[2][38]

• Research consistently shows that among psychosocial variables such as locus of control and perfectionism, body image distortion is the strongest predictor of clinical eating disorders and disordered eating behaviors.[38]

• Body image distortion is a critical factor in the development and maintenance of anorexia nervosa, bulimia nervosa, body dysmorphic disorder, and is a known risk factor for the development of Binge Eating Disorder.[38]

• In addition to increasing the risk of suicide and self-harming behaviors, eating disorders have the highest mortality rate among all psychiatric conditions.[38]

• Clinical eating disorders and disordered eating can disrupt almost all major organ systems, including physiologic disruptions such as bradycardia, hypotension, and hypothermia. Medical complications of anorexia nervosa include:[38]

Cardiovascular: bradycardia and hypotension, mitral valve prolapse, sudden death, arrhythmia, refeeding syndrome, echo changes

Endocrine and Metabolic: amenorrhea, infertility, osteoporosis, thyroid abnormalities, hypercortisolemia, hypoglycemia, neurogenic diabetes insipidus, arrested growth

Dermatologic: dry skin, alopecia, lanugo hair, starvation-associated pruritis

Hematologic: pancytopenia due to starvation, decreased ESR

Gastrointestinal: dysphagia, constipation, refeeding pancreatitis, hepatitis, acute gastric dilatation, delayed gastric emptying

Pulmonary: aspiration pneumonia, respiratory failure, spontaneous pneumothorax, emphysema

Neurologic: cerebral atrophy

Ophthalmic: lagophthalmos

Deterrence and Patient Education

The accessibility and enthusiasm of adolescent students to engage in educational activities make the school environment an appropriate place to implement health promotion programs. Several studies have suggested school-based educational programs to improve body image and to help prevent eating disorders. School curricula include different mandatory health topics such as lifestyle and personal development problems. Few major school-based interventions to prevent eating disorders and improve the body image have been the object of study to date that all employ a similar information-based strategy. These interventions focus on providing information about eating disorders and body image-related issues to female secondary school students in a traditional structured classroom setting. Topics include sociocultural development of body image and body image ideals, healthy eating, the potential risks of caloric restriction, and expectations about the perfect body is covered. The results of these interventions have suggested that although this approach is likely to improve the knowledge of eating disorders and disordered eating, it is unlikely to influence the thoughts, attitudes, beliefs, and behaviors that affect the development of eating disorders. Research frequently shows that the information-giving approach to educate body image is fundamentally flawed and is ineffective in improving body image and eating behaviors in adolescent females.[48]

Parents also play an essential role in the development of body image, body dissatisfaction, and eating problems; thus, developing prevention programs for parents of children in preschool age seems to be relevant. Nevertheless,  the consequence of such prevention efforts required to be assessed by useful, sensitive, and valid measures. A recent systematic concluded that there is limited data for such interventions and their effectiveness in modifying parent behaviors associated with child body image and eating problems. Several measures of parental feeding practices have been developed, validated, and widely used, such as the Pre-schooler Feeding Questionnaire and Child Feeding Questionnaire. These measures evaluate how parents feed their child and how their feeding practice influence on children’s weight and eating behavior. However, there is no validated measure that assesses parent knowledge and behaviors related to body image and healthy eating patterns in children.[17]

Enhancing Healthcare Team Outcomes

The complexity of many mental disorders requires an interprofessional treatment approach, and the role of good interprofessional teamwork to treat mental disorders is increasingly recognized. Eating disorders, as essential manifestations of body image distortion often require interprofessional collaboration. The interprofessional team approach for patients with disordered eating enjoys wide acknowledgment as the best practice. Team members include mental health professionals, nutritionist, social worker, internist, endocrinologist, gastroenterologist, pharmacist, and specialty trained nurses that all require experience in the care of patients with disordered eating. Although each member of the team has unique responsibilities and skills concerning patient care, there is substantial overlap in the responsibilities of the treatment team to help recovery from disordered eating.[49] Education of the patient and their family is critical to prevent the high morbidity. The dietitian should educate the patient and family on the nutritional significance and limiting exercises. The pharmacist should inform patients and their family on medication abuse such as laxatives or weight loss medications. This portion of the care can benefit from input and collaboration with a pharmacist, who can also monitor for drug interactions in the patient's regimen. The outcomes can improve only through monitoring and close follow up of the patient. Nurses can influence the quality of care by managing the complexity in their relationships with these patients. The mental health nurse can educate the patient on easing stress, overcoming emotional issues, and changes in behavior. Even with an interprofessional treatment approach, the overall prognosis is poor, and all clinicians must consider early comprehensive intervention.[50] [Level III]

Individuals with BDD are generally secretive about their symptoms. Healthcare professionals may indeed stigmatize these patients by considering only an actual disfigurement as worthy of medical attention. Hence, patients with BDD are more likely to present to healthcare professionals with complaints such as social anxiety or depression since these are less stigmatizing. Healthcare professionals should provide accurate information to patients and their families and help them to understand their symptoms are involuntary.[51] [Level I]

PCPs and other nonpsychiatric physicians may tend to refer the patient to another nonpsychiatrist or even a cosmetic specialist; however, this is unlikely to be helpful.[30] BDD patients and their mental health providers need to be aware that non-mental health interventions appear unlikely to treat BDD symptoms successfully.[41] The clinicians can inform the patient that he or she can receive cosmetic treatment if they want, although the clinician can not recommend a cosmetic solution. It is also helpful to acknowledge to the patient that the clinician worries the patient will be unhappy with the outcome of cosmetic treatment. The patient needs to be encouraged to seek appropriate psychiatric treatment to decrease distress and live a more productive life.[30] Dermatologists and surgeons should screen patients for BDD and accurately diagnose this disease since available psychiatric treatments are up-and-coming for patients with this distressing disorder. Mental health professionals specialized in BDD should work in partnership with dermatologists and cosmetic surgeons to ensure that a validated screening system and agreed referral criteria are in place. They also should provide training opportunities for dermatologists and cosmetic surgeons to help in recognition of BDD.[51] [Level I] Specialty trained nurses in eating disorders and psychiatry monitor patients, coordinate between other providers and provide feedback to the team. [Level V]

Body image distortion and its accompanying disorders is a complex clinical scenario and require an interprofessional team approach, including physicians, specialists, specialty-trained nurses, and pharmacists, all collaborating across disciplines to achieve optimal patient results. [Level V]