Tyler B. Mason1,2, Kathryn E. Smith2,3, Jason M. Lavender4, and Stephen A. Wonderlich2,3
1Department of Psychology, University of Southern California, Los Angeles, CA, USA
2Neuropsychiatric Research Institute, Fargo, ND, USA
3Department of Psychiatry and Behavioral Science, University of North Dakota School of Medicine and Health Sciences, Grand Forks, ND, USA
4Department of Psychiatry, University of California, San Diego, CA, USA
Body image involves a person's subjective appraisal of his or her own physical characteristics and qualities (e.g., Pruzinsky, 2004; Sarwer & Steffen, 2015). Body image concerns are highly prevalent in Western societies and are more prominent among women (Fiske, Fallon, Blissmer, & Redding, 2014), although they occur among both men and women. Additionally, body image concerns appear to be common across the lifespan (Fiske et al., 2014). Evidence suggests that poor body image can negatively affect psychosocial functioning (Patalay, Sharpe, & Wolpert, 2015), health behaviors (Neumark‐Sztainer, Paxton, Hannan, Haines, & Story, 2006), and overall quality of life (Mond et al., 2013). Conversely, positive body image is protective against numerous mental health problems and serves to increase overall psychological well‐being (Gillen, 2015). Further, several mental disorders associated with mortality and reduced quality of life are marked by disturbances in body image (e.g., body dysmorphic disorder, eating disorders). Of particular relevance to the field of clinical health psychology, poor body image occurs in a variety of medical conditions and clinical populations (e.g., individuals with obesity, patients with cancer). Understanding and routinely assessing body image concerns may have utility in alleviating health problems and reducing further physical and mental health complications. In this entry, we describe body image in the field of clinical health psychology including risk factors and correlates of body image concerns.
Body image concerns are important health symptoms to consider in clinical health psychology and occur in a myriad of medical conditions and diseases. The most prominent medical condition associated with poor body image is obesity. This relationship is in part propagated by a pervasive cultural emphasis on thinness and the associated stigmatization of individuals who are overweight or obese (Puhl & Latner, 2007). Thus, body image concerns may be a problem among any medical and psychiatric patients who present with co‐occurring obesity. Further, while weight loss usually improves overall body image, body image concerns, specifically related to excess skin, may be present among individuals who lose a great deal of weight, notably those who receive bariatric surgery (Song et al., 2006). However, body contouring after large weight loss has been shown to be related to improvements in body image (Song et al., 2006).
Body image concerns are also relatively common in patients with various types of cancer and other medical conditions. For example, disturbances in body image have been observed in patients with breast cancer (Lasry et al., 1987), cervical cancer (Hawighorst‐Knapstein et al., 2004), and head and neck cancers (Fingeret et al., 2013). Further, side effects of cancer treatment such as alopecia have also been associated with increases in body image concerns (Münstedt, Manthey, Sachsse, & Vahrson, 1997). Other medical conditions and diseases that may involve body image concerns are inflammatory bowel disease and Crohn's disease (Saha et al., 2015), endometriosis (Melis et al., 2015), lupus (Jolly et al., 2012), and systemic sclerosis (Ennis, Herrick, Cassidy, Griffiths, & Richards, 2012). Children and adolescents with various medical conditions may experience a similar pattern of concerns. For instance, in a meta‐analysis examining relationships between body image and chronic illness among children and adolescents, Pinquart (2013) found that children and adolescents with obesity, cystic fibrosis, scoliosis, asthma, growth hormone deficits, spina bifida, cancer, and diabetes rated their bodies less positively than healthy comparison groups.
While body image concerns may be associated with particular diseases, certain characteristics of diseases and associated treatments may also be related to the manifestation of body image concerns. For example, disease activity and chronicity, treatment type, treatment complications, and presenting symptoms in various medical conditions may affect individuals' body image in various patient populations (e.g., Bullen et al., 2012; Ennis et al., 2012; Fingeret et al., 2013; Rhondali et al., 2013). Of note, treatment and improvement in disease activity are not always associated with improvements in body image (Saha et al., 2015). In addition, treatment for medical conditions may worsen body image—for example, increased body dissatisfaction has been reported after mastectomy in breast cancer patients (Lasry et al., 1987). On the other hand, some medical treatments have been shown to reduce body image concerns more so than others (e.g., ileal pouch–anal anastomosis in ulcerative colitis patients; Larson et al., 2008; and robotic thyroidectomy among patients with papillary thyroid carcinoma; Lee et al., 2014).
A host of risk factors for body image concerns has been identified. Demographic, sociocultural, and psychosocial variables are among the most widely studied and will be the focus of this section of the chapter. First, demographic characteristics including gender, race/ethnicity, and sexual orientation are associated with body image concerns. Women, Caucasian individuals, and men who identify as gay or bisexual are generally are more at risk for body image concerns; however, differences in these groups appear to be narrowing in some respects (Field et al., 2014; Morrison, Morrison, & Sager, 2004; Roberts, Cash, Feingold, & Johnson, 2006). Second, numerous sociocultural variables (i.e., characteristics of society that includes cultural norms for beauty and attractiveness) have been linked to body image concerns. For instance, greater media consumption and exposure (e.g., magazines, television, social media, Internet‐based media) has been found to be associated with increased body image concerns (Grabe, Ward, & Hyde, 2008). Relatedly, internalization of societal norms regarding thinness and perceived sociocultural pressure for thinness are strongly related to increased body image concerns (Stice & Whitenton, 2002). Further, social comparisons, which involve tendencies to compare oneself with other people, are also highly predictive of body image concerns, especially in response to comparisons in which the other person is perceived as more attractive (Myers & Crowther, 2009).
Various psychosocial aspects also have been found to be related to elevated body image concerns. For example, certain personality characteristics are related to poor body image, including neuroticism and other forms of trait negative affectivity as well as perfectionism (Pennesi & Wade, 2016). Lifetime and recent stressful events including weight teasing and discrimination are also related to body image concerns (Eisenberg, Neumark‐Sztainer, Haines, & Wall, 2006). Furthermore, greater internalizing problems, notably anxiety, depression, and low self‐esteem, are related to increased body image concerns (Patalay et al., 2015; van den Berg, Mond, Eisenberg, Ackard, & Neumark‐Sztainer, 2010). Finally, interpersonal and social deficits including attachment insecurity (Abbate‐Daga, Gramaglia, Amianto, Marzola, & Fassino, 2010), poor peer relationships (Schutz & Paxton, 2007), and decreased social support (Stice & Whitenton, 2002) are also associated with increased body image concerns.
Studies of clinical populations have primarily shown body image concerns to be related to reduced disease‐specific and overall quality of life, as well overall psychological well‐being (Rhondali et al., 2013; Yagil et al., 2015). Furthermore, Bullen et al. (2012) reported that preexisting disturbances in body image predicted later psychopathology in patients with colorectal disease. Thus, body image concerns related to disease and medical problems, as well as preexisting body image concerns, may impact mental and physical health outcomes. Additionally, in the broader body image literature, poor body image has been found to be related to numerous domains of mental and physical health, maladaptive behavior, and overall functioning. Below, we briefly review relationships between body image and each of these domains.
Poor body image is broadly associated with poorer overall mental health (Mond et al., 2013), as well as lower self‐esteem and increased internalizing symptoms among men and women (Field et al., 2014; Patalay et al., 2015). In addition, body image concerns are related to interpersonal and social problems and difficulties (Gupta & Gupta, 2013; Mond et al., 2013). Other research has also found increased body image concerns to be associated with suicidal ideation (Gupta & Gupta, 2013) and sleep problems (Gupta, Gupta, & Knapp, 2015).
Body image concerns are related to a number of eating‐ and weight‐related behaviors, including dietary restriction, use of diet pills, diuretics, and laxatives, and self‐induced vomiting (Andrew, Tiggemann, & Clark, 2016; Neumark‐Sztainer et al., 2006). Additionally, among men in particular, body image concerns in the form of a desire for greater muscularity are associated with use of steroids and other appearance‐ and performance‐enhancing drugs (Murray, Griffiths, Mond, Kean, & Blashill, 2016). In turn, maladaptive eating patterns, such as binge eating and overeating, have been shown to be related to increased body image concerns (Neumark‐Sztainer et al., 2006).
In addition to being broadly associated with eating‐ and weight‐control behaviors, body image concerns are a central feature in certain psychiatric disorders and commonly occur in others. For example, the experience of persistent, intrusive thoughts about one or more perceived flaws in one's appearance is the hallmark feature of body dysmorphic disorder. In addition, body image concerns are most notably associated with eating disorders and are included in nearly all models of disordered eating (Pennesi & Wade, 2016). Specifically, the overvaluation of body shape and weight is a defining characteristic of anorexia nervosa (AN) and bulimia nervosa (BN) and is also commonly observed in subclinical eating disorders and binge eating disorder (BED), the latter of which is characterized by a high prevalence of overweight and obesity.
While research has typically assessed relationships between body image concerns and eating‐ and weight‐related behaviors, there is evidence that body image concerns are associated with other health‐related behaviors as well. For example, studies have found associations between lower body satisfaction and lower physical activity, increased screen‐based media use, and increased smoking among males and females (Farhat, Iannotti, & Caccavale, 2014; Neumark‐Sztainer et al., 2006). In addition, in an online sample of women, body dissatisfaction was related to less skin screening behaviors and more alcohol consumption, whereas body appreciation was related to more sun protection behaviors (Andrew et al., 2016). Among males, elevated concerns over muscularity among males have been associated with a number of problematic behaviors, including binge drinking and drug use (Field et al., 2014; Jampel, Safren, & Blashill, 2015). Finally, one study of body image concerns and physical health found that chronic weight dissatisfaction predicted elevated risk for type 2 diabetes, over and above weight status (Wirth, Blake, Hébert, Sui, & Blair, 2014).
Body image concerns have also been shown to be related to multiple domains of sexual functioning (Woertman & van den Brink, 2012). For example, women with body image concerns report more appearance concerns during sexual interactions, lower levels of desire and arousal, and decreased pleasure and sexual satisfaction (Woertman & van den Brink, 2012). In addition, a recent meta‐analysis showed that increased body dissatisfaction was related to less condom use self‐efficacy (Blashill & Safren, 2015). Further, body image concerns were associated with risky sexual behavior among women (Merianos, King, & Vidourek, 2013). Conversely, body appreciation was related to better sexual functioning among women (Satinsky, Reece, Dennis, Sanders, & Bardzell, 2012).
Body image concerns are prominent in numerous clinical populations, both medical and psychiatric. Body image concerns are generally associated with reduced quality of life in patients and may lead to the development of additional mental and physical health problems. In addition, poor body image may be associated with engaging in numerous maladaptive behaviors including unhealthy eating‐ and weight‐related behaviors, alcohol and drug use, and risky sexual behaviors. Poor body image may also be associated with less positive health behaviors, notably cancer screening behaviors (Andrew et al., 2016) and reduced physical activity. Due to the wide range of negative outcomes related to body image concerns, screening for body image concerns in clinical health settings is imperative in order to provide optimal medical care and reduce disease burden.
Tyler B. Mason, PhD, is an assistant professor in the Department of Preventative Medicine at the University of Southern California. He received his PhD in applied psychological science in 2015 and BS in psychology in 2010 from Old Dominion University. His primary research interests include etiology and treatment of binge eating and obesity.
Kathryn E. Smith, PhD, is a T32 postdoctoral research fellow at the Neuropsychiatric Research Institute. She received her BA in psychology from Macalester College and her PhD in clinical psychology in from Kent State University. Her primary interests include emotion regulation and co‐occurring psychopathology in eating disorders and obesity.
Jason M. Lavender, PhD, is an assistant research scientist in the Department of Psychiatry at the University of California, San Diego. He completed his undergraduate education at Duke University and his PhD in clinical psychology at the University at Albany, SUNY. His research addresses emotion, neurocognition, and personality in eating disorders.
Stephen A. Wonderlich, PhD, is the Chester Fritz distinguished professor and associate chairperson in the Department of Psychiatry and Behavioral Science at the University of North Dakota, chair of eating disorders and co‐director of the Eating Disorder and Weight Management Center at Sanford, and president and scientific director of the Neuropsychiatric Research Institute.