Body Image
Diana Luskin Biordi
Patricia McCann Galon
INTRODUCTION
Of all the prisms through which culture can be viewed, body image is one of the most prevalent and profound. From the abstract concepts of beauty, sexuality, and community to the tangibles of health, mobility, and communication, the ideal of the perfect body prevails. Against that culturally normed model of the perfect body, one forms an image of one’s own body that is reflective of the culture and social interactions. The perfect body changes from culture to culture and across time. Models of ancient Greeks, for example, show muscular young men and women with broad shoulders, small waists, and narrow pelvises, whereas today’s prevalent American model is waif-like thinness with body tone for women and defined muscularity for men. When and how an individual differs from the cultural norm requires social and emotional management to explain. Therefore, individuals use a frame of reference for their own bodies, which is shaped by the prevailing body norm of the culture, and perhaps, by subcultures within the larger culture. If one’s body image differs from the body norm, social and physical rationalizations come into play. Insofar as those rationalizations themselves are exaggerated from yet other norms, healthcare interventions may be required.
One’s mental image of one’s physical self is one’s body image. Individual body images may change over time, depending on life tasks such as learning one’s gender role, performing a job or sport, creating a family, body or brain chemistry and structure, or aging. In chronic illness, body image is both a modifier of, and is modified by, the illness. Chronic illness, in its capacity to change the body, typically necessitates revisitations to one’s body image. These revisitations are modified by the psychology of the individual and his or her perceptions of an ideal. That is, the individual will have to decide, consciously or unconsciously, whether to persevere in meeting an ideal body image (the culturally defined perfect body), reformulate or readjust the ideal to conform to his or her own attributes, or reject the ideal.
Significant research in body image has occurred only recently, despite being a common subject in the literature since the late 1800s. In fact, since 2004, an entire journal has been devoted to Body Image (published by Elsevier). In nursing, there appears to be a large gap between an initial spate of studies in the 1970s to those of the 1990s, with a substantial increase
in research since 2000. Most of the literature examining body image is found in practice disciplines such as nursing, medicine (e.g., neurology), bioengineering, psychology, and vocational counseling. This literature focuses on neurologic and psychological studies of person and gender, health studies on chronic illness (particularly, cancer), and most recently bariatric studies on obesity. In addition, some body image studies focus on plastic surgery or reconstruction, which are increasingly used by a number of persons for cosmetic reasons and/or as interventions for illness, accidents, obesity, or for other treatments (Frederick, Lever, & Peplau, 2007). The current emphasis on youth and beauty in American culture and the antiobesity objectives of the nation (through the campaigns of First Lady Michelle Obama; see also Healthy People 2020) are expected to spur more research on body image.
in research since 2000. Most of the literature examining body image is found in practice disciplines such as nursing, medicine (e.g., neurology), bioengineering, psychology, and vocational counseling. This literature focuses on neurologic and psychological studies of person and gender, health studies on chronic illness (particularly, cancer), and most recently bariatric studies on obesity. In addition, some body image studies focus on plastic surgery or reconstruction, which are increasingly used by a number of persons for cosmetic reasons and/or as interventions for illness, accidents, obesity, or for other treatments (Frederick, Lever, & Peplau, 2007). The current emphasis on youth and beauty in American culture and the antiobesity objectives of the nation (through the campaigns of First Lady Michelle Obama; see also Healthy People 2020) are expected to spur more research on body image.
Definitions of Body Image
Body image is defined and referred to in two ways. The most prevalent definition of body image is the psychological view, in which body image is the mental image of one’s physical self, including attitudes and perceptions of one’s physical appearance, state of health, skills, and sexuality. Another term with the same definition is body schema.
Body image is how one perceives one’s own body, including its attractiveness, and how that body image influences interactions and others’ reactions. Therefore, body image is not only the way people perceive themselves but, equally important, the way they think others see them. Consequently, body image is a major delimiter of social interactions, and as such has a profound effect on physical health, social interaction, psychological development, and interpersonal relationships. Moreover, because body image is conceptual, even if it is expressed inferentially, as in anorexia nervosa, most of the literature describes body image from information taken from cognitively intact, communicative human beings. Issues of profoundly retarded individuals and their body images, for example, are more likely examined from the perspective of others as they regard the person’s body and whether it deviates from norms, as well as the reactions of others to the person.
The second way in which body image is used is more neurologic and technical. In this definition, body image has been shown to relate to the association of brain areas, particularly the motor cortex, with portions of the body, such as the limbs or lips. Particular parts of the brain are also associated with the sense of the body in space and that the self is localized, or embodied, within body borders (Blanke, 2007). Embodiment is important to the models of the self or self-consciousness, and also, more tangibly, of body parts properly belonging to one’s person. Abnormalities in embodiment can lead to such distress as “amputation desire” or “amputation envy,” in which persons are profoundly frustrated by their sense that one of their body parts (limbs) does not “belong” to them, and actively seek its removal to satisfy their sense of body/embodiment (Mueller, 2007-2008). Voluntary movement of body limbs, or sensations, often of pain, have been shown to be linked to limbs, teeth, or breasts, when certain brain areas or neurons are invoked. Thus, body image is defined and discussed in the theory, empiricism, and language of brain, neuropathology, neurology, anatomy, and/or physiology (Lewis, 1983; Mueller, 2007-2008; Ramachandran, 2004; Ramachandran & Rogers-Ramachandran, 2007).
It is interesting that the symptoms of the psychiatric diagnosis, body dysmorphic disorder (BDD), also are characterized as both psychological and neuropathological. Persons with BDD, a chronic disorder, suffer distress and functional impairment due to a preoccupation with even a slight defect in their appearance. The preoccupation can progress to a delusional state. BDD is a fairly common disorder with an estimated prevalence of about 0.7-1.7 % of the population, but it often goes unrecognized. Persons with BDD often seek plastic surgery or dermatologic treatment for this “abnormality” but are never satisfied with the results and thus may seek repeated procedures (Feusner, Yaryura-Tobias, & Saxena, 2008). In addition they believe they are mocked by others for their defect and see themselves as generally less healthy and capable than the rest of the population (Didie, Kuniega-Pietrzak, & Phillips, 2010).
One can develop BDD in response to brain trauma or disease in the central nervous system, especially in the temporal lobe area. About 8% of persons with BDD can identify relatives with obsessive compulsive disorder or BDD, indicating inheritability. Phillips and Hollander (2008) suggest that persons with BDD have fundamental differences in visual processing with a focus on the specific rather than on an overall picture, both in consideration of the self and their environment. It is also speculated based on neuropsychological evaluation that emotional arousal may contribute to the attentional bias (concentration on defect) and social anxiety associated with the disorder.
Body image is referred to in two other ways in the literature. First, body image is conceptualized as a final product or end state—a state of being, such as, “Charles’s body image is that of a muscular young man.” Second, body image can be portrayed as a process—a continuous examination by the self or others, whereby one’s body is defined and redefined. In both of these conceptualizations, there are a number of factors that influence body image. Furthermore, the attitudes and perceptions about one’s body guide evaluation and investment in body image, which affect physical and psychosocial functioning. Attitudes about body image are related to one’s self-esteem, interpersonal functioning, eating and exercise patterns, self-care activities, and sexual behaviors (Cash & Fleming, 2002; Peelen & Downing, 2007).
In summary, body image is theorized as conceptual and neurologic, with each concept feeding into the other. Body image is one’s perception of one’s body and its interactions with others. It includes a sense of ownership and boundaries of one’s body, the image of which is constructed psychologically and through the neurologic system of the brain—through proprioception (the sense of the body in space), vision, and the vestibular system. Body image can be thought of as both a process and an end product, and one’s body image affects physical and psychosocial functioning.
Historical Foundations of Body Image
Although body image has been discussed in the literature since the 1880s, it was not until Schilder presented his work in 1935 that a new understanding of this concept arose. In The Image and Appearance of the Human Body, Schilder (1950) explored the dimensions of body image: “The image of the human body means the picture of our own body which we form in our mind, that is to say the way in which the body appears to
ourselves” (p. 11). He believed that the perception of one’s body is based on a three-dimensional image that comprises physiologic, psychological, and social experiences.
ourselves” (p. 11). He believed that the perception of one’s body is based on a three-dimensional image that comprises physiologic, psychological, and social experiences.
Schilder’s work affected subsequent researchers, even into the 21st century. Critiquing Schilder’s broad and complex theory, Cash and Pruzinsky (1990) claim that Schilder’s chief contribution was not just the idea of body image, but the idea that body image has “central pertinence not only for the pathologic but also everyday events of life” (p. 9). Later, Cash and Pruzinsky (2002) assert that Schilder “single handedly moved the study of body image beyond the exclusive domain of neuropathology” (p. 4).
Most current discussions now frame body image as having a perceptual component, a psychological component, and a social component (Cash & Fleming, 2002; Thompson & Gardner, 2002; Thompson & Van Den Berg, 2002). For example, with regard to eating and weight disorders, the perceptual component is the accuracy of the person’s body size estimation, the psychological component is the person’s attitudes or feelings toward their own body, and the social component might be the cultural context in which body image is assessed.
Like others, Thompson and Gardner (2002), and Cash and Fleming (2002) argue that body image is not a simple perceptual phenomenon, but is highly influenced by cognitive, affective, attitudinal, and other variables. Thompson has been attributed as the impetus in the 1990s to a more clinically and physiologically based concept of body image, particularly in examining eating disorders (Cash & Pruzinsky, 2002). Building on his work, research later focused on cultural overlays, including feminist critiques of the 1990s, and later, the effects of family or ethnicity on body image. More recent work in the 2000s is refocusing on the physiologic basis of body image, while attending to more evidence-based interventions on body image and its effects (Cash & Pruzinsky, 2004).
Currently, major empirical analyses of body image focus on neurology, particularly those studies involving the brain and associated visual, vestibular, vascular, and proprioceptor stimuli. Impactful studies by Ramachandran and Rogers-Ramachandran (2007) indicate that body image can be shaped and changed by the brain. Using vision and proprioceptor cues, they were able to map where in the brain (somatosensory, motor, and parietal cortices) cues were received to fashion a virtual sense of body that did not correspond to actuality. The idea that body image can be so profoundly shaped by the brain has important implications for theory and for treatment. In a related set of studies, Ramachandran (2004) indicates that when motor signals are sent to muscles, duplicate signals are sent to the brain’s parietal lobes, giving a sense of real limbs when there are actually amputations, leading to the phenomenon of phantom limb syndrome. Therefore, as is known in the field of prosthetics, amputees who are unable to incorporate a change in body image that genuinely indicates a lost limb were shown to be unable to use prosthetics effectively.
Of particular importance to healthcare professionals in chronic illness is the empirically derived idea that the perceptual elements of body image are complex. Fisher (1986) found that people not only compartmentalized their body image, but also differed in how they did so. Some localized their body image, whereas others had a more global view of their body. For instance, people with serious body defects might approach their bodies as separate regions,
specifically isolating the defective region so that it will not influence their overall evaluation of self. Fisher believed that this ability suggests “important defensive and maturational significance in how differentiated one’s approach to one’s body is” (p. 635). He also argued that the rubric of body image itself is vague, representing a number of dimensions of the same and different constructs. New neurologic data (Ramachandran [2004]; Ramachandran and Rogers-Ramachandran [2007]) indicate that certain brain regions governing specific body parts play a role in whether body images can be sustained or demarcated as separate. For example, clients with left-sided hemiplegia caused by a stroke often experience a dissociation from their paralyzed limbs.
specifically isolating the defective region so that it will not influence their overall evaluation of self. Fisher believed that this ability suggests “important defensive and maturational significance in how differentiated one’s approach to one’s body is” (p. 635). He also argued that the rubric of body image itself is vague, representing a number of dimensions of the same and different constructs. New neurologic data (Ramachandran [2004]; Ramachandran and Rogers-Ramachandran [2007]) indicate that certain brain regions governing specific body parts play a role in whether body images can be sustained or demarcated as separate. For example, clients with left-sided hemiplegia caused by a stroke often experience a dissociation from their paralyzed limbs.
Factors in the Definition of Body Image
Definitions of body image, although varied, share similarities. Common to many of the definitions is the belief that body image develops in response to multiple sensory inputs (visual, tactile, proprioceptive, and kinesthetic). Therefore, although physicality is included in one’s body image, body image is subjective and dynamic because it is influenced by multiple factors (Cash, 2002; Pruzinsky, 2004). Body image is brought into the immediate focus of the individual by pain, physical or psychological illness, age, or weight (Krueger, 2002). Kinesthetic perceptions of function, sensation, and mobility are also part of our image. For example, children without sensation of body parts (e.g., spina bifida) often do not include in their art those body parts where they lack sensation.
Body image also includes feelings and thoughts. How one thinks and feels about one’s body will influence social relationships and other psychological characteristics. Furthermore, how people feel and think about their bodies influences the way they perceive the world (Cash & Fleming, 2002).
Nezlek (1999) found three factors were included in the definition of body image. These included body attractiveness, social attractiveness (how attractive people believed others found them to be), and general attractiveness. For both men and women, self-perceptions of body attractiveness and social attractiveness were positively related to intimacy. Because body attractiveness is an important function of body image, this concept frequently is confused with body image itself; however, body image encompasses more than attractiveness.
Many definitions of body image today involve the notions of the real and the ideal. Theorists would argue that the ideal image of one’s self and the real image must be compatible, or dissonance results. A discrepancy between the real and the ideal body image may lead to conflicts that adversely affect personality, interactions, and health. For example, “normative discontent” refers to the pervasive negative feelings women and girls experience when they negatively distort their appearance, experience body image dissatisfaction, or overevaluate appearance in defining a sense of self (Striegel-Moore & Franko, 2002).
For the healthcare professional, definitions of body image indicate the complexity of the concept, but more importantly, emphasize how significantly the client’s cultural, social, historical, and biological factors affect body image. Perhaps even more important to healthcare professionals and their professionally derived norms is that body image and the factors affecting it are not merely cosmetic. A client’s perceptions and
attitudes about his or her body can affect health, social adjustment, interpersonal relationships, and general well-being. These perceptions are profoundly affected by chronic illness, as shown in this text.
attitudes about his or her body can affect health, social adjustment, interpersonal relationships, and general well-being. These perceptions are profoundly affected by chronic illness, as shown in this text.
Perhaps because body image is so vital to issues of ordinary health as well as chronic illness, it has come to be associated with, or even confused with, several other terms. The terms body image, self-concept, and self-esteem are frequently used interchangeably. Body image is not the same as body attractiveness but is related to both attractiveness and to self-esteem. Body image is a mental image of one’s physical self, moderated by one’s psychology and the social environment, and as is being discovered, by certain physiologic parameters of the brain. Body image, thus, is an integral component of selfconcept. Self-concept is the total perception an individual holds of self—who one believes one is, how one believes one looks, and how one feels about one’s self (Mock, 1993). Research extends self-concept to include not only ongoing perceptions of one’s self, but also the idea that self-concept so mediates and regulates behavior that it is one of the most significant regulators of behavior (Markus & Wurf, 1987). Self-concept also is used to describe roles in which one casts the self, which can further stretch, and perhaps muddy, the concept. Finally, self-esteem is related to “the evaluative component of an individual’s self-concept” (Corwyn, 2000, p. 357).
Factors Influencing Adjustment to Body Image
Meaning and Significance
As critical as each influence may be to the individual’s adaptation, it is most important that the meaning of the event to the individual be understood. Knowing that clients may compartmentalize both the meaning and the body’s parts, the healthcare professional must recognize and accept how each client assesses the changes occurring in his or her body, their importance, and the way that the client chooses to incorporate (or not) changes into their body image. Thus, treatment of chronic illness and by association body image, functionality, or appearance cannot be far removed from the meaning attributed to such by the client or significant other.
In most cultures, body parts carry emotional attribution quite aside from functionality or appearance. The hands, for instance, are critical portrayals of the meanings and metaphysics of religions, whether shown invitingly open, in clasped position, or thumbs and forefingers together. Similarly, the mind is associated with the brain and all the significance attached to it in a knowledge society, whereas the heart is universally seen as the font of emotions. The heart is, to many, the symbol of love, courage, and life, and the seat of joy, hate, and sorrow. Indeed, in some cultures, the heart is seen as the location of the soul. Consider the emotional significance, then, that damage to the heart would engender in the body image of the affected client. Most nurses have been taught about clients who, after sustaining a myocardial infarction, are so anxious that they become a “cardiac cripple,” owing to their fear of death from exercise or normal activity. Clearly, the self-image of such clients has sustained a serious insult. Dementia creates issues of selfimage not only for the person undergoing the change, but also for significant others in the interactions and subsequent reappraisals. How many times have nurses heard families say that they “no longer know their loved one” as the disease progresses?
To counter the insult to body image and functionality, and knowing likely prognoses, the healthcare professional must reassure the client and family about their perceptions of body image and help them reconcile to the present and future realities of the situation. That is, the healthcare professional should make efforts to reconcile the ideal body image of the client with the current attributes of the person and encourage the client to move toward a more realistic body image, while recognizing that, for the client, losing their desired body image can create a grieving process that must also be managed.
Body image and the insults to functionality from chronic illness cannot be isolated from the meaning and significance the client gives to them. Furthermore, the meaning and significance to family members or significant others can also play an important role in the client’s response. These are crucial factors to consider in offering and performing effective and sensitive care. Of all the aspects of body image in chronic illness, the appreciation and understanding of the meaning and significance to the client are areas to which nursing can most contribute. The client’s meaning and significance of the change in body image must not be overlooked or down played. Nursing’s empathic and holistic approach can be of great value in this arena of health care.
The cause of the person’s chronic illness and associated insult to one’s body image can be an important coping factor. If the change was caused by an accident, healthcare mismanagement, or personal negligence, the person may harbor unresolved anger, blame, and shame. The person may also be guarded about sharing and discussing such matters, which confounds recovery and makes it more difficult. On the other hand, if the cause was recommended or was a life-saving intervention, the person perceives the body image insult as an unavoidable consequence and a relatively small price to pay (Rybarczyk & Behel, 2002).
Another important factor the nurse must not forget is the “fifth vital sign,” or pain. If pain is associated with the cause of the body image change, the meaning and significance of the altered body image can be negatively influenced. Pain may also nourish a persisting and even worsening negative body image and impair recovery in functionality (Rybarczyk & Behel, 2002). Hence, it is essential to assess the person for pain and discomfort, and to treat accordingly.
Influence of Time
The length of time during which body changes occur may influence one’s body image and subsequent psychological adjustment (White, 2002). Changes in body image may occur slowly, over a lifetime, or quickly, within hours or days. Although some might argue that more time gives individuals greater opportunity to reformulate a body image, the fact remains that some individuals will never adapt their body image to the ideal they hold or their current attributes. A person with type 2 diabetes may have a slow progression of changes and ample time for denial and grief resolution, whereas trauma and sudden illness, such as head trauma, stroke, or certain surgeries, may lead to abrupt changes in the body and in body image. Individuals who experience sudden traumatic illnesses have no warning, and thus little opportunity to adjust to the changes (Bello & McIntire, 1995). A classic example is the lag between limb amputations and phantom pain, where clients are confused about whether they still have the appendage. To adjust to rapid change, the client must grieve the loss as well as physically adjust to the changes.
The client who cannot cope with the dysfunction is at high risk for infection, noncompliance with therapeutic care, depression, social isolation, and obsession with or denial of the changes in body image (Dropkin, 1989).
The client who cannot cope with the dysfunction is at high risk for infection, noncompliance with therapeutic care, depression, social isolation, and obsession with or denial of the changes in body image (Dropkin, 1989).
The permanence of the change in appearance also affects adjustment to changes in body image. A person may better cope with changes in appearance that are temporary (i.e., temporary ileostomy) more so than those that are permanent (i.e., limb amputation). However, adjusting to body image changes depends partly on the meaning the individual ascribes to the changes and, in some cases, the length of time during which the change occurs (White, 2002).
Social Influences
Each sociocultural group establishes its own norms governing the acceptable, especially in terms of physical appearance and personality attributes (Jackson, 2002). Societies can hold a persistent, pervasive view with standards that dictate ideal physical appearance and role performance. These standards, although some with caveats, serve all members of that social group, including those who have chronic illness and those who do not.
Groups target their social influence and affect the self-images of individuals. Family relationships are often important to the person with a chronic illness and can impact their initial perception of their own body image when they become chronically ill. Negative family reactions about appearance, behavior, performance, and body image have been linked with recurrent poor body image consequences (Byely, Archibald, Graber, & Brooks-Gunn, 1999; Kearney-Cooke, 2002). Peers are also important mediating groups, particularly for those who are uncertain how to structure their lifestyles (e.g., adolescents). On one hand, peers can help shape conformance to a model. An example is the currently popular view of the muscle-bound, minimal-body-fat male model that is popular among young people (Olivardia, Pope, & Hudson, 2000). On the other hand, peer groups can call into question the appropriateness of such modeling for their own age group (e.g., older adults’ perception of the aforementioned male model).
Persons with disfigurements are often, with little choice in the matter, forced to deal with their body image and the prevailing societal view. Depending on the visibility of the disfigurement and the coping of the disfigured person, sanctions such as staring, whispering, or shunning can negatively affect body image and personal value (Pruzinsky, 2002; Rumsey, 2002).
Untoward issues of body image often begin early in life. There is evidence now that in the United States and Britain, both girls and boys as young as 6 years old are overly conscious of their body weight and would begin dieting in an attempt to meet social norms of idealized thin and handsome young men and women. These young children, especially girls, are reported to be influenced by parental models and fashion magazines toward a desired thinness (Fornari & Dancyge, 2006; McCabe, Ricciardelli, & Lina, 2005; Lowes & Tiggemann, 2003). The body image issues that begin in early years often persist throughout adolescence and into adulthood (Striegel-Moore & Franko, 2002).
The effect of society and environment on body image is reciprocal. Societal reactions can affect body image, but the individual is not entirely passive and so can react in opposition to such standards. Nevertheless, societal influences weigh heavily on behavior and body image, frequently leading to stereotypical
assignments that affect individual body image adjustments. For example, persons with craniofacial disfigurement, or those who are chronically obese, have been subjected to societal reactions and expectations of ideal beauty throughout their lives. Over the years, having been constantly compared with the “ideal” beautiful or thin person, the individual with chronic illness has had to manage their own responses as well as those of others in the obvious discrepancy between an ideal body and their own real bodies.
assignments that affect individual body image adjustments. For example, persons with craniofacial disfigurement, or those who are chronically obese, have been subjected to societal reactions and expectations of ideal beauty throughout their lives. Over the years, having been constantly compared with the “ideal” beautiful or thin person, the individual with chronic illness has had to manage their own responses as well as those of others in the obvious discrepancy between an ideal body and their own real bodies.
Cultural Influences
Many aspects of culture affect body image. A cultural map has been suggested by Helman (1995) in which the members of a particular cultural or social group share a view of the body. This cultural map tells individuals how their body is structured and how it functions, includes ideal body definitions, and identifies “private” and “public” body parts as well as differentiating between a “healthy” and an “unhealthy” body (Helman, 1995).
The perceptions of health and illness and their effects on body image vary from culture to culture. In Altabe’s (1998) study on ideal physical traits and body image, ethnic groups were similar in their identification of ideal body traits but different in assigning values to the body traits (e.g., valuing skin color or breast size). Findings indicated that African Americans had the most positive self-view and body image, whereas Asian Americans placed the least importance on physical appearance. Some non-Caucasians had a more positive body image than did Caucasians.
African Americans view health as a feeling of well-being, the ability to fulfill role expectations, and experiencing an environment free of pain and excessive stress. In the United States, the Latino cultural perception of health is being and looking clean, feeling happy, getting adequate rest, and being able to function in expected roles. An imbalance in the emotional, physical, and social arenas may produce illness. Hispanic individuals often do not seek health care until they are very sick, and those with chronic illness may view themselves as victims of malevolent forces, attributed to God or punishment. Native Americans view health as a balancing of mind, body, spirit, and nature. The practice of medicine is viewed as cooperative and offers choice and individual involvement in the pursuit of health.
Southeast Asian cultural health beliefs focus on the concept of yin and yang (balance) and maintaining this balance to achieve wellness. Additionally, obesity was once viewed as a sign of contentment and socioeconomic status in this culture. South Asians are particularly prone to subsequent cardiac and diabetic conditions because of lack of exercise, cultural emphases on high caloric foods, and religious and genetic influences (Pella, Thomas, Tomlinson, & Singh, 2003).
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