1

Body Image

Tyler B. Mason1, Kathryn E. Smith2,3, Jason M. Lavender4, & Stephen A. Wonderlich2,3

1
University of Southern California, Los Angeles, California
2
Neuropsychiatric Research Institute, Fargo, North Dakota
3
Department of Psychiatry and Behavioral Science, University of North Dakota School of

Medicine and Health Sciences, Fargo, North Dakota

4
Department of Psychiatry, University of California, San Diego, La Jolla, California
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Abstract

Body image is a multidimensional construct that refers to a person’s subjective appraisal of his

or her own physical characteristics and qualities. Body image concerns are prevalent in a number

of medical conditions and clinical populations (e.g., individuals with obesity, patients with

cancer). In addition, several psychiatric disorders are associated with extreme disturbances in

body image, including body dysmorphic disorder and eating disorders. Concerns over body

image (e.g., body dissatisfaction) can also negatively affect psychosocial functioning, health

behaviors, and overall quality of life. Positive body image, however, is an important buffer

against mental health problems. This entry provides an overview of body image in the field of

clinical health psychology, as well as risk factors and complications of body image concerns.

Keywords: body image; body dissatisfaction; eating disorders; obesity

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Body image involves a person’s subjective appraisal of his or her own physical

characteristics and qualities. 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 and Clinical Health Psychology

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
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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., 2010), 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 (2014) 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
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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—e.g., 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).

Risk Factors for Body Image Concerns

A host of risk factors for body image concerns have 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 which

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
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concerns (Stice & Whitenton, 2002). Further, social comparisons, which involve tendencies to

compare oneself to 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.

Correlates and Consequences of 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 pre-

existing 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 pre-

existing 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
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domains of mental and physical health, maladaptive behavior, and overall functioning. Below,

we briefly review relationships between body image and each of these domains.

Psychological functioning and mental health. 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).

Eating- and weight-related behaviors. 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).

Psychiatric conditions. 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
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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.

Other health behaviors. 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).

Sexual health. 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
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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).

Conclusions

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.
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Suggested Readings

Grogan, S. (2006). Body image and health contemporary perspectives. Journal of Health

Psychology, 11, 523-530. doi:10.1177/1359105306065013

Pruzinsky, T. (2004). Enhancing quality of life in medical populations: A vision for body image

assessment and rehabilitation as standards of care. Body Image, 1, 71-81.

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Author Biographies

Tyler Mason, Ph.D., is an Assistant Professor in the Department of Preventative Medicine at the

University of Southern California. He received his Ph.D. in Applied Psychological Science in

2015 and B.S. in Psychology in 2010 from Old Dominion University. His primary research

interests include etiology and treatment of binge eating and obesity.

Kathryn Smith, Ph.D., is a T32 Postdoctoral Research Fellow at the Neuropsychiatric Research

Institute. She received her B.A. in psychology from Macalester College, and her Ph.D. in clinical

psychology in from Kent State University. Her primary interests include emotion regulation and

co-occurring psychopathology in eating disorders and obesity.

Jason Lavender, Ph.D., 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 Ph.D. in clinical psychology at the University at Albany, SUNY. His research

addresses emotion, neurocognition, and personality in eating disorders.

Stephen Wonderlich, Ph.D., 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.