Developmental psychology: concepts and applications

Developmental Psychology

Body Image, Body Health, and Pathology

Eating disorders and anorexia are becoming more commonplace today, and this is true particularly of young women, although older people and men sometimes also suffer from them. It is important to look at this issue as it relates to body image and how one feels about one's body, but also important to see it in the light of the way that one trust's oneself and others, and the hope for the future that is sometimes absent from the lives of these individuals. Such problems as depression can often play a large role in whether someone has problems with body image and eating disorders.

The National Eating Disorders Association (NEDA, 2002) states that eating disorders' incidences have doubled within the past 20 years, and the average age range for an eating disorder is from 10-25 years old, with two peaks around 13-14 and 18-19 years old. These are the most critical times, when eating disorders are the most likely to develop. Approximately one out of ten adolescents and university students have eating disorders and almost 95% of them are female (Grilo, Masheb, & Wilson, 2001). This indicates that, although men are sometimes affected to this, eating disorders are largely a problem of the female population. Furthermore, five to ten million girls and women as well as one million males suffer from some type of eating disturbances (NEDA, 2002).

These may not be classified as disorders and may not be as significant as anorexia and bulimia, but they are still significant enough to be noticed and important to those that suffer from them and those that are trying to help these people recover from their eating problems. As reported by Manley & Leichner (2003), anorexia nervosa, one of the eating disorders, has the greatest mortality rate of any psychiatric illness. Much of this comes from the fact that this type of illness can cause someone to literally starve themselves to death, while still believing that they are fat. This type of disorder is very unhealthy, even if the patient survives, because the lack of proper food and the nutrition that comes with it is extremely hard on all of the systems of the body, especially when it goes on for an extended period of time. Some of these anorexic individuals battle this problem for years. The longer it goes on, the harder it is for them to overcome it and the larger toll it takes on their health, both mentally and physically.

The National Institute of Mental Health (NIMH, 2001) indicates that the mortality rate for teenagers with eating disorders is 12 times higher than any other cause among females 15-24 years old. In most instances, death occurs due to starvation with serious body damages, leading to cardiac arrest, electrolyte imbalance, and suicide. The idea that suicide can stem from an eating disorder such as anorexia also indicates that many of these individuals may be suffering from other problems, such as anxiety disorders and depression, both of which have a relatively high rate of suicide.

According to Sansone & Levitt (2002), the presence of self-harm among eating disorders patients amounts to 25%. Anorexic patients attempting suicide total 16%, while bulimics amount to 23% outpatients and 39% inpatients. When alcoholism and bulimia co-exist, the rate of suicidal attempts rises to 54%. These statistics appear to be alarming, and are almost too large to comprehend, but they must be understood and dealt with so that the rates of these problems can come down. One of the main problems with this, however, is that these people often conceal their eating disorders for a very long time, and it is only realized when the person becomes so sick that they require a doctor's care. Bulimics also often maintain a normal weight range, so their binging and purging behavior can go unnoticed for quite some time, even by those that are close to them.

According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), the criteria for an eating disorder includes a refusal to maintain body weight of at least 85% of what is expected for a specific age and height. Furthermore, inability to keeping weight at or above patterns, failure to accept weight gain during the growth period, and an intense fear of gaining weight or becoming fat even when underweight, may also categorize eating disorders. Other factors include denial of the seriousness of the current low body weight and disturbance in the way one's body weight or shape is experienced on self-evaluation. In addition, eating disorders can be also categorized in girls whose menstrual cycles are absent for at least three consecutive months, although they have experienced menarche.

Eating disorders are characterized by behaviors surrounding weight and food issues. It varies from dieting to starving, from binging to strenuous exercising, from excessive eating to self-induced vomiting or other purging methods such as diuretics and laxatives. Eating disorders can be life threatening if not treated in a timely manner. Eating disorders are not due simply to failure of will or behavior, but to maladaptive eating patterns. In other words, these individuals lack the will power to change their behavior, but they have also gotten so caught up in the eating pattern that has led to the disorder that they are no longer aware of how to correct this, and often do not see that there is anything to correct. Those maladaptive patterns are usually treatable not only medically for several complications, such as kidney and heart conditions, but also psychologically, as in many cases they are accompanied by depression, anxiety, or chemical dependence (NIMH, 2001).

The concept of normal eating includes being able to choose enjoyable foods, eat when hungry and continue to eat until satisfied. Furthermore, normal eating allows giving oneself permission to eat without feeling guilty when feeling full. On the other side, eating disorders, disordered eating, and body intolerance are culturally informed and mediate problems. Those cases are growing in today's society. They are especially prevalent in the Western civilization, although researches are still seeking for the reason (Keel & Klump, 2003). It appears, however, that the media and how it represents women (i.e. you cannot be popular/pretty/wealthy/etc. unless you are thin) contributes quite strongly to these eating disorders.

Men and women approach anxieties about their body image and self-worth differently when thinking about their bodies. Females get their sense of self-worth from upholding caring relationships, whereas males tend to derive their self-worth from instrumental achievements. Men are more likely to use sexual perversion, masturbation, and pornography in an attempt to have their dependency needs met, and are more likely to be associated with their disillusioned narcissistic needs (Sands, 2003). Further research needs to be conducted on males and eating disorders, to find out why and how they are not as prone to disordered eating. Whether this is a by-product of the media and its images, whether men are just emotionally stronger in this regard, or whether there is some other mitigating factor should be considered. This is important, because there is clearly some reason that women are so much more prone to eating problems such as anorexia and bulimia than men are.

Women are more likely than men to keep their thoughts and feelings inside in order to avoid confrontations, and usually put the needs of others before their own needs in a way to maintain and solidify their relationships. Simultaneously, they are more prone to present themselves loving, compliant, caring, and nurturing, while suppressing anger and hostility. Since women are highly and emotionally influenced by their peer's evaluations and externalized self-perceptions, mostly from society standards, they are inclined to use those perceptions as their parameters to judge themselves. Furthermore, women experiencing eating disorders tend to use third person ideals and references to think about their own bodies as if seeing themselves through someone else's eyes (Frank & Thomas, 2003).

Ethics is also an important consideration in these eating disorders, although one might not connect the two things upon first examination. When psychologists treat patients, they look for the inner problems and the deeper meanings that manifest themselves in a particular disorder or problem. Often, these are ethical or moral in nature. The person might feel badly about their childhood, they may regret their lack of morals, they may have problems with peer pressure, etc. They also could be the victim of molestation, which would have to be reported to the police, regardless of whether the psychologist is supposed to keep the patient's information confidential. Because of these issues and others, teenagers and young women with eating disorders and the psychologists that are trying to help them must understand about ethical dilemmas and deal with them in the best way possible as they arise, so that the patient can receive the largest benefit.

The etiology of eating disorders is not fully determined. However, researches show that physical or genetic predisposition and neurobiological reasons (family history of eating disorders), psychological (family history of depression, anxiety, bipolar disorder), and sociocultural (media, television, sports, peer, and family pressure), appear to have some influence. Several psychiatric disorders might lead to increasing risk of eating disorder, including neurotic and depressive symptoms, bipolar disorder, manic depression, anxiety, obsessive-compulsive personality characteristics, history of sexual abuse, severe family problems, extreme social pressures, insecurity, being controlled by others, distorted body image, etc. (NIMH, 2001). In addition, extreme negative dissatisfaction with their bodies may be a factor in its existence, even though not a predictor of eating disorders (Leon, Fulkerson, Perry, & Cudeck, 1993).

According to Johnson, Cohen, Kotler, Kasen, & Brook (2002), teenagers diagnosed with depression might be at a higher risk for the onset of eating disorders during middle adolescence and early adulthood, because eating disorders and depression in children and adolescents are closely related. Nevertheless, disruptive disorders might also contribute to recurrent fluctuations in teenagers' weight. In other words, most teenagers will have some fluctuations in their weight when they are happy or when they are depressed. These are normal and temporary, but eating disorders go well beyond that.

Klump, McGue, & Iacono (2002) state that genetic predisposition to be nervous, anxious, and pessimistic could cause girls to focus on their bodies during adolescence and puberty more than girls with no predisposition to worrying about their body image. Girls prone to worries do not know how to deal with stressors, leading them to anxiety symptoms, and possibly disordered eating behaviors (Leon, et al., 1993). Another group consists of perfectionists, model daughters, high achievers, bright dutiful, with low self-esteem, irrationally believing to be fat (Leon et al., 1993).

Nowadays the number of girls experiencing menarche at a younger age has increased, and numerous theories have risen suggesting the correlation between early menarche and increased risks for the development of eating disorders (APA, 2003). Contrarily, Stice, Presness, & Bearman (2001) report surprising findings that state early menarche does not offer increased risk for eating disorders. It is clear from the disagreement that there is no definite understanding whether early menarche is related to eating disorders in general, or whether other genetic factors and environment issues also play a part to tie early menarche to eating disorders in some girls.

Psychodynamic literature describes three deficits that might predispose to anorexia nervosa. First, clients having difficulties with separation and autonomy usually had enmeshed relationships with parents. Second, clients presented affected regulation involving direct expression of anger and aggression. Finally, clients negotiated their psychosexual development. Those deficits might increase vulnerability to cultural pressures for achieving a stereotypical (i.e. thin) body image possibly leading to eating disorders.

Many cultures have emphasized and associate female beauty to thinness, and emphasizing that people should be unhappy with their body image if it does not conform exactly to what the 'perfect' image is. Those thoughts permeate society, implying that to be attractive women must be thin. Society and the media have placed great pressure, through movies, television shows, and commercials, by demanding women to be thin. Therefore, female self-concept and achievement aspirations are greatly influenced by the subtle implications of sex role stereotyping in television commercials, including unchallenged messages about attractiveness (Keel & Klump, 2003).

Normally, eating disorders are associated with adolescence. However in today's society children have been exposed to an extremely thin standard of attractiveness. Since television represents a major source of influence and information in the lives of children, they are particularly influenced and usually accept what happens on television as reality (Johnson, Cohen, Kotler, Kasen, & Brook, 2002). Many children start disliking their bodies even before they start school. Stice, Presnell, & Bearman (2001) state that in the last decade, children as young as eight have been treated for eating disorders, and more than half of the girls in first through fifth grades claimed to have dieted at some point. One of the main causes of treatment delay is related to the inability of many pediatricians to recognize the beginning stages of an eating disorder (Bohen, 2001).

Professionals can sponsor health education as an active role in minimizing media influence by showing young adults how to lose weight properly, what their healthy weight should be, and how to feel better about their body image. Parents may promote an atmosphere of acceptance leading to a comfortable balance between the adolescent desire to be feminine and their need to become competent and autonomous. Parents should act as role modes displaying positive coping skills and healthy weight understanding, by conveying that appearance is not the most important part of someone's identity. Beauty comes form the inside and a person's personality and character are valuable.

Another major societal influence lies on the obsession with obesity and its risks by causing media to promote all kinds of dieting. Although obesity leads to dangerous health factors, the reverse is as much dangerous (Keel & Klump, 2003).

Family factors might be a good predictor in distinguishing eating disorder girls from the ones without disordered eating. An interesting finding is reported in Pike & Rodin (1991), describing that mothers who are dissatisfied with their family system functioning as more prone to have daughters with eating disorders. Those mothers think that their daughters should lose weight and many times find their daughters less attractive than the girls own judgments.

In a study conducted by Mallinckrodt, McCreary, & Robertson (1995), those reporting weak bonds with their mothers and those with the lowest levels of social competencies, presented higher number of eating disorder symptoms. Furthermore, victims of incest showed a higher eating disorder rate (47%) than sexually abused clients (22%). Most reports from incest survivors describe their family environment as less cohesive and expressive, with both parents less emotionally expressive, more intrusively, controlling, and more conflictual.

Sands (2003) describe in his study that females suffering from anorexia present an irrational fear of their bodies, even more than food. Likewise, they are afraid of their desires for emotional nourishment as much as they are afraid of food. It is suggested that this behavior is due to a need to be in control and food would be the only thing they could actually control. Moreover, it is important to access not only eating disorder symptoms, but also the presence of concomitant self-harm behavior, since they co-exist in many cases (Sansone & Levitt, 2002).

Treatment options consist of complete assessment with medical evaluation to rule out other physical conditions, and mental health assessment preferably by an eating disorder expert. The most effective proved treatment is a team approach including psychotherapy, individual, family, group therapy, and support groups couple with medical treatment from a primary care physician (PCP) or from specialists due to medical complications (Les Parrott III, 1997). Moreover, nutritionists and psychopharmacological interventions such as psychotropics and mood stabilizers used under careful supervision were found to be beneficial in several cases (Maine, 2000). Some family approaches used with relative success in treating eating disorders include Carl Whitaker symbolic-experiential therapy and Minuchin's family-focused structural approach (Gurman & Kniskern, 1991).

Cognitive therapy remains the strongest psychosocial intervention and is the preferable therapy treatment modality. Because of the absolutes, human beings demand perfection and whatever does not fit this irrational thought will generate frustration and sorrow (Kirkpatrick & Caldwell, 2001). According to cognitive theory, it is necessary to dispute irrational beliefs in order to transform them into more realists ones, bringing fulfillment (Corey, 1996). The goal of this treatment modality is to minimize emotional disturbances as well as self-defeating behavior. This is usually done by the acquisition of a more realistic philosophy of life.

Some other goals of cognitive therapy are reducing the tendency of blaming self and others, and increasing self-interest, self-direction, self-acceptance, social interest, self-responsibility for disturbance, tolerance, flexibility, commitment, risk taking, acceptance of uncertainty, and higher tolerance of frustration (Galotti, 1994). Medications to aid in minimizing self-destruction behavior might be a part of the treatment, including atypical antipsychotic in conjunction with selective serotonin reuptake inhibitors (SSRI) and/or anticonvulsant (APA, 2003).

Cognitive therapists display full acceptance and tolerance towards client, though confronting nonsensical thinking, by showing client irrational thoughts, taking client beyond awareness, and by demonstrating how their illogical thinking keeps disturbances active (Kaplan & Carter, 1995). Furthermore, therapists should help client to modify thinking, abandon irrational ideas, and to challenge the development of a more rational philosophy of life, in order to avoid future irrationality (Wilson & Fairburn, 1993).

Cognitive therapists use a lot of modeling and teach new methods for changing thinking, feelings and behavior; however therapists do not control clients. Therapists are also concerned about establishing a supportive, helpful facilitative alliance, working in collaboration with clients, knowing that empathy, genuineness, and unconditional positive regard help to build up rapport with clients, and increase effectiveness of therapy. Furthermore, therapists should promote free expression of individual's perspectives (Granvold, 1994). Client role is to accept own beliefs as the cause for own disturbances, and work towards changing the behaviors into new ones that are more acceptable. In cases of eating disorders, the faulty behavior is related to unrealistic assessment of self as being overweight in spite of the real weight, usually below ideal body weight (Jongsma & Peterson, 1995).

Cognitive behavior therapy is one of the best approaches to deal with children and adolescents, focusing in modeling, didactic instruction, and experiential learning. This therapy modality helps children and youth to develop inner control and overt behavior. Furthermore, it provides children and adolescent with a better understanding of self-management, self-control, self-reinforcement and coping skills (Feindler, 1986). Therapists might use empowering techniques and display a caring and open attitude along with humor to teenagers, to develop trust. It is designed to help correct abnormal attitudes and beliefs about body shape and weight (Corey, 1996).

Eating disorder patients often present distorted beliefs, unrealistic guidelines, and suffer extremely guilt. Therefore, cognitive therapy may help guiding their beliefs and detecting faulty thinking, as well as leading patients to modify their irrational thoughts and behaviors (Wilson and Fairburn, 1993). In addition, it is important to consider faulty cognitions that promote self-harm behavior, such as cutting, burning, or scratching, and use cognitive restructuring to promote the elimination of those faulty behaviors (Sansone, Levitt, & Sansone, 2003).

Normal eating habits may replace the dysfunctional dieting and may produce therapeutic improvement. Cognitive therapy is very effective, especially in a family therapy session. Other modalities producing effective results include art therapy, spiritual support based upon individual's orientation, and even some self-help literature might be beneficial to some. However, clinicians should be knowledgeable to carefully select the best fitting literature to each individual (Levitt & Sansone, 2003).

Prevention programs are not as efficient as they intended to be. Although looked upon as highly effective, Mann, Nolen-Hoeksema, Huang, Burgard, Wright, & Hanson (1997) prevention programs did not prevent eating disorder behavior. Contrarily, the study concluded that those students attending the program had more symptoms of eating disorders than the students who did not attend the program, while there was no difference between the two groups prior to the intervention. According to the authors of this research, secondary prevention received too much emphasis, though reducing the stigma. The unintentional reduction of stigma directed participants to believe in a faulty idea that eating disorders were somehow normal. On the other side, many participants were given the impression that any insignificant changes in eating habits were classified as eating disorders.

Mann et al. (1997) believe that the idea of normality possibly led participants to consider that it was easy to get in and out of the eating disorder continuum, nevertheless eating and not eating could be done without any problems. Prevention might still be the key to overcoming this problem, but only if correctly facilitated.

One study, conducted by Harris (1995), utilized 144 young women and various measures that dealt with body image. The results of this study are important to examine here, because different types of analyses, including multiple regression analysis and canonical analyses were used to obtain answers to how these women really felt about their bodies and how these feelings affected their lifestyles, self-image, and their trust in themselves and others.

The work that Harris (1995) did, although almost 10 years old at this point, is very significant. For that reason, the tables that she used in her work, as well as her explanations for them, will be reproduced here. Some explanation for them is also necessary, and will be included after the tables. The tables themselves, however, are relatively self-explanatory, since they state what tests were used to produce the results, and the notes that Harris (1995) included after them indicate what type of analysis was done on the data that was collected. All tables and the notes that follow them come from Harris (1995), and she should receive proper credit for them, as they are not the creation of this researcher.

TABLE 1

Means and Standard Deviations of the Student Development Task and Lifestyle Inventory and the Five Measures of Body Image

Variable M. SD

SDTLI-1

PUR

39.90 9.62

MIR

17.42 5.45

AA

4.933 2.77

SL

4.381 2.35

INT

12.48 5.24

MBSRQ

Appearance Evaluation subscale 3.13 .771

Fitness Evaluation subscale 3.38 .720

Health Evaluation subscale 3.49 .707

Body Cathexis Scale 3.35 .491

Body Dissatisfaction subscale of EDI 12.94 8.22

Notes: SDTLI-1 = Student Development Task and Lifestyle Inventory; PUR = establishing and clarifying purpose task; MIR = mature interpersonal relationships task; AA = academic autonomy task; SL = Salubrious Lifestyle scale; INT = Intimacy scale; MBSRQ = Multidimensional Body Self-Relations Questionnaire; EDI = Eating Disorders Inventory. Higher scores on the SDTLI-1, MBSRQ, and Body Cathexis Scale indicate higher levels of psychosocial development, satisfaction, and more positive attitudes toward body parts and processes, respectively. Higher scores on the Body Dissatisfaction subscale of the EDI indicate higher levels of dissatisfaction with the body.

Measures of body image, including the Appearance, Fitness, and Health Evaluation scales of the MBSRQ, the Body Cathexis Scale, and the Body Dissatisfaction subscale of the EDI, were treated as one set of variables, and the five subscales of the STDLI-1 constituted a second set. The results indicated a statistically significant relationship between variable sets, Pillai's V = .84, F (25,495) = 3.98, p = .0001. I obtained one significant canonical root that accounted for 37.3% of the variance between the canonical variates. Only the structure coefficients greater than .30 were treated as meaningful (Pedhazur, 1982; Tabachnick & Fidell, 1989).

Based on interpretation guidelines, the structural coefficients presented in Table 2 show that, in the set of body image variables, the root was characterized by consistent, moderate, positive loadings on four body image measures and a moderately negative loading on the Body Dissatisfaction subscale of the EDI. For the set of psychosocial development variables, the root was characterized by a moderately positive loading on PUR and a high positive loading on SL. That is, college women who favorably evaluated their bodies on appearance, fitness, and health, reported satisfaction with the body, and indicated less dissatisfaction with the physical self were also likely to report well-defined educational goals and to describe themselves as active self-directed learners. Also, these women were likely to report making healthy lifestyle choices.

TABLE 2

Structure Coefficients for the Canonical Analysis of the Student

Development Task and Lifestyle Inventory and Measures of Body Image

Variable Structure coefficient

Predictor

Multidimensional Body Self-Relations Questionnaire

Appearance Evaluation subscale .607

Fitness Evaluation subscale .623

Health Evaluation subscale .581

Body Cathexis Scale .610

Body Dissatisfaction subscale of EDI -.514

Criterion

Student Development Task and Lifestyle Inventory

Establishing and clarifying purpose task .365

Mature interpersonal relationships task .285

Academic autonomy task .269

Salubrious Lifestyle subscale .746

Intimacy subscale

.149

[R.sup.2]

.611

Note. [R.sup.2] = % variance accounted for.

Notes: I conducted MAX R. regression to determine which variables belonged in the two predictive models. The MAX R. procedure is similar to the stepwise multiple regression procedure but allows for more possible predictive combinations.

When I used the SL scale as a dependent variable and the five types of body image as the independent variables in the first model, the regression demonstrated that 57% of the variance in scores that reflect engaging in wellness and health-related practices was predicted by the body image factors (p [less than] .0001). As shown in Table 3, the first body image measure, the Fitness Evaluation scale, accounted for 40% (p [less than] .0001) of the effect, with the second scale, Health Evaluation, adding another 9% (p [less than] .0001). The addition of the third measure of body image, Body Dissatisfaction, augmented the effect by 6% (p [less than] .0001), with 2% additional variance explained by the scores on the Body Cathexis Scale.

The best predictors of PUR were responses to items on the Body Cathexis Scale and the Appearance Evaluation subscale (Table 4). This finding suggests that women who are satisfied with specific body parts and processes and report favorable feelings toward their appearance also show advancement in educational, career, and life management/planning, as well as overall purpose. However, these two types of body attitudes accounted for only 9% of the variance in the establishing and clarifying purpose task. Such a small amount of variation explained by body image variables indicates that other relevant factors not considered in the present study may explain this aspect of women's psychosocial development.