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Body Image in Mood and Psychotic Disorders
Body Image in Mood and Psychotic Disorders E Hollander, J Siragusa, and SY Berkson, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, USA © 2012 Elsevier Inc. All rights reserved.
Glossary catatonia Characterized by either rigidity or extreme laxness of limbs. cenesthesia The general feeling of inhabiting one’s body that arises from multiple stimuli from various bodily organs. hypothalamic–pituitary–adrenocortical (HPA) axis Complex set of direct influences and feedback interactions among the hypothalamus, the pituitary gland (a pea-shaped structure located above the hypothalamus), and the adrenal glands (located on top of each kidney) that controls reactions to stress and regulates many bodily processes such as
Introduction
Body Image and Major Depressive Disorder
This article describes body image disturbances in mood and psychotic disorders, focusing specifically on four diagnoses: major depressive disorder (MDD), bipolar disorder (BD), schi zophrenia, and somatic-type delusional disorder. For each of these diagnoses, we explore clinical symptomatology and the extent to which body image plays a role in the course of illness. Even though body image may be integral to the phenomenol ogy of these disorders, relatively little is known about the underlying mechanisms of body image pathology in each of them.
Body Image and Depression Body Image and Depressive Symptoms in Nonclinical Samples The causal relationship between poor body image and depres sive symptomatology is still largely unclear. While some consider body image distortion to be among the cognitive symptoms of depression, others sidestep causality and are only comfortable noting the association between depressed subjects and aesthetic dissatisfaction. Although the causal directionality has yet to be fully elucidated, prospective studies have indicated that body image dissatisfaction is an important precursor or risk for depression. Each person, to some extent, is concerned with their appearance – how they present themselves to the world. Some may feel they are too chubby, or that their hair is too thin, or their complexion is imperfect. Yet much of the basis for developing validated scales of body image assessment is predicated upon the fact that body image disturbance involves a triad of dissatisfaction, distress (or dysphoria), and dysfunction (or impairment). In other words, in subjects in whom body image becomes pathological, the degree of concern, mental preoccupation, and emotional distress are significant enough to interfere with social and occupational functioning. Encyclopedia of Body Image and Human Appearance, Volume 1
digestion, immune function, energy storage, and expenditure. insula A portion of the cerebral cortex involved in diverse functions such as consciousness, emotions, and interpersonal experience. polymorphism A particular point mutation in genotype that leads to a unique phenotype. prefrontal cortex Anterior part of the frontal lobes of the brain that is responsible for executive function (planning complex cognitive behaviors and decision making). visceral hypersensitivity A condition wherein pressure and sensation that is normally not painful or not perceived is felt as intense pain.
The core symptom of MDD is depressed mood or loss of interest in activity that is present most of the day nearly every day for at least 14 days. Common symptoms include insomnia or hyper somnia, psychomotor agitation or retardation, recurrent thoughts of death, and diminished ability to think and concentrate. MDD has a lifetime prevalence of approximately 15% and may be as high as 25% for women. The course of MDD is variable. Some people have isolated episodes that are separated by years without any depressive symptoms. Others have a cluster of episodes or increasingly frequent episodes as they age. Episodes of MDD often follow a severe or significant life stressor, such as death of a loved one or divorce. MDD is associated with a 1.5–3.0 times increased likelihood of having a first-degree biological relative with the disorder. The Diagnostic and Statistical Manual of Mental Disorders: Text Revision, 4th edition (DSM-IV-TR) lists several specifiers to further classify the diagnosis. MDD ‘severe with psychotic features’ often signals the presence of delusions or hallucina tions and is further subdivided into mood-congruent or mood-incongruent psychotic features. The former category is characterized by delusions or hallucinations whose content is entirely consistent with typical depressive themes of personal inadequacy, guilt, death, and so on. Presumably, this subdivi sion of MDD is most likely to include distortions of body image. Patients may see themselves as misshapen, ugly, or physically deformed, which is consistent with general feelings of inadequacy. The degree to which MDD patients with promi nent body image disturbance actually receive this specific diagnosis has yet to be studied. Patients with MDD can be characterized by alterations in mood, cognition, perception, sensation, and behavior, all of which may impact their bodies and body image. Their emo tions and cognitions tend toward ruminations, self-blame, and increased association of their self with negative emotions. Their behavior is often characterized by persistent somatovegetative symptoms. At the same time, their altered sensation and
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perception may manifest itself as apparent hyperawareness of bodily changes. Interestingly, patients with traits of anxiety and depression have been found to have a decreased pain tolerance and demonstrate a kind of visceral hypersensitivity or intero ceptive awareness. It seems that depressed patients may actually ‘feel more’ in a literal sense. The connection between anxious/depressive traits and visceral hypersensitivity has been extensively studied in irritable bowel syndrome. One hypothe sized mechanism for the condition suggests that end-organ sensitivity (via nociceptors), endogenous modulation (involving the cerebral cortex and brain stem), spinal hyperex citability (via nitric oxide activation), and long-term hyperalgesia interact in such a way as to disrupt the enteric nervous system and thereby alter bowel function. Mood and self-esteem are related to one’s perception of and satisfaction with one’s body. Research supports the link between poor body image and higher incidence of depression and depressive symptomatology. Patients suffering from major depression report less favorable evaluations of their physical aesthetics. They often feel that their entire bodies, or specific features, are ugly, unattractive, and unappealing. Evidence also suggests that low self-esteem (which is moderately correlated with body image dissatisfaction) is a premorbid predictor of depression. Low self-esteem also persists during euthymic phases of MDD. In the case of MDD, a poor body image associated with low self-esteem is usually mood congruent, or consistent with overall feelings of low self-worth. The results of some studies have shown that body image disturbance is asso ciated with depression, while other studies suggest that depression simply predisposes individuals to body image dis turbance. Interestingly, depression is related to the subjective assessment of one’s own physical attractiveness, but not neces sarily to observer-rated physical attractiveness. That is, depressed persons are more likely to think they are unattractive despite how they are perceived by others. This is consistent with research showing that nondepressed subjects display more positive distortions of self-directed social events as well as more positive distortions of control over environmental events. Imaging studies of patients with MDD have indicated an association between emotional and cognitive abnormalities and altered neural activity in the medial cortical regions, parti cularly the dorsomedial prefrontal cortex, which is believed to be central to emotional regulation. However, the neural correlates of abnormal somatovegetative symptoms and inter oceptive awareness in MDD remain unclear. Recently, a relationship between abnormal body perception and reduced activity within the anterior insula has been identified. The anterior insula is a region that has been linked to interoceptive awareness of stimuli such as heartbeat, gastric distension, and pain. Generally, delusional thought processes are associated with conditions that affect the limbic system and basal ganglia – regions that are also highly implicated in the pathophysiology of depression. The limbic system is involved in a variety of functions including emotion, behavior, long-term memory, and olfaction. The basal ganglia are also associated with a variety of functions including motor control and learning. Existing data fail to adequately address the question of whether patients with poor body image can be considered to be in a constant state of emotional distress. Surmising that this is the case, this would have far-reaching implications in terms of the physiological consequences of poor body image. Stress
has been shown to be one of the most potent triggers of depression. In animal models, external stressors cause serotonin dysregulation, leading to decreased brain monoami nergic activity and the state of depression. External stressors likely interact with genetic variations (such as specific serotonin transporter gene polymorphisms) to produce the wide variability in the clinical presentation of MDD. The stress-related alterations in the central nervous system in turn activate two neuroendocrine pathways called the hypothalamic–pituitary–adrenocortical (HPA) axis and the sympathetic–adrenomedullary (SA) system. Persistent HPA and SA activation can lead to downstream abnormalities in certain physiological processes such as platelet function, auto nomic tone, inflammation, and endothelial function. Poor or distorted body image, via emotional stress and its negative effects on various physiological processes, may be related to poor health outcomes (e.g., cardiovascular disease). These pathways may help explain the increased incidence of certain medical conditions among depressed patients. One meta-analysis concluded that depressed patients are three times more likely to be noncompliant with medical treatment recommendations. Thus, treatment of depression pharmacolo gically and/or psychotherapeutically may improve patients’ depressive symptoms, body image, and overall physiological health. The extent to which patients with MDD and mood-congruent body image concerns have improvement in body image upon successful treatment of depression is cur rently not fully known.
Body Image in Bipolar Disorder The BDs include bipolar I disorder, bipolar II disorder, cyclothymia, and BD not otherwise specified. The discussion here will focus on bipolar I disorder, which has a worldwide prevalence of 3–5%. The essential feature of bipolar I disorder is a clinical course that includes the occurrence of one or more manic episodes or mixed episodes. According to the DSM IV-TR, a manic episode is defined as a distinct period of abnor mally or persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary). Some of the criteria for a manic episode listed in the DSM-IV-TR may include body image aberrations such as inflated self-esteem or hypersexual behavior. For a mixed epi sode, criteria for a manic episode and for a major depressive episode (except duration) are met nearly every day for at least 1 week. BD most often starts with depression (75% of the time for women, 67% for men). Most patients experience both depressive and manic episodes, although 10–20% experience only manic episodes. In mania or hypomania (manic symptoms that are clini cally significant but insufficient to cause social/occupational impairment), patients may display an enhanced or inflated sense of body image, such that one may feel especially attrac tive or sexual. As unstable mood is an integral part of BD, patients may have fluctuating perceptions of their body image. Generally, it seems that the higher the degree of fluctua tion in self-esteem, the worse the prognosis in patients with BD. One study measured self-esteem daily over a 1-week period and found that BD patients had more fluctuations in self-esteem compared to MDD patients and controls. Similarly, studies
Body Image in Mood and Psychotic Disorders have found that cyclothymic temperament, which entails con tinuous shifts in mood and perception as well as variations in self-esteem, is more severe in BD patients than in MDD patients or controls. Unstable self-esteem, in combination with unrea listic standards of success, may predispose individuals with BD toward extreme shifts in self-evaluation, which may include appraisal of one’s physical attributes (i.e., body image). Low self-esteem is believed to be a risk factor contributing to the onset of BD in genetically vulnerable individuals. An early manifestation of low self-esteem in BD was indicated by a study in which adolescents with BD were found to have lower self-esteem than adolescent controls. This may be related to the relatively high incidence of childhood traumas (e.g., sexual or physical abuse) reported by BD patients (one study found more than a 50% incidence of traumatic events in youth with diagnosed BD). Another explanation, which is referred to as the complication or scar hypothesis, is that low self-esteem is a consequence of BD. As widely documented, many BD patients experience a number of impairments due to the illness, such as cognitive deficits and occupational and social difficulties, which may contribute to the development and maintenance of low self-esteem. Living with BD may also disrupt identity formation. BD patients often have difficulty in establishing a coherent identity due to their changing and contrasting mood episodes. Conversely, disruption of identity formation may worsen the experience of BD. That is, an unstable self-image may cause unpredictable behaviors and interpersonal conflicts. These negative experiences in turn may damage self-esteem and dar ken perceptions of one’s self and body image. Thus, the relationship may be cyclical. BD may also give rise to low self-esteem through the negative stigma attached to the illness. One study found that awareness of stigmatization was corre lated with lower self-esteem in remitted BD patients. A multimodal theory explains BD as a specific dysregulation of the behavioral activation system (BAS), a system involved in behavioral and neurological responses to cues signaling oppor tunities to achieve or lose rewards. According to the expanded version of this theory, high and low BAS activation can lead to mania and depression, respectively, depending on the type of eliciting events and how they are appraised in terms of rele vance and efficacy. Research points to a specific BAS-related cognitive style in BD characterized by performance evaluation, autonomy, self-criticism, and an emphasis on goal attainment. This can manifest in some BD patients as a futile (and frustrat ing) quest for physical and cosmetic perfection (skin, weight, etc.). Since low self-esteem seems to fit thematically into such a cognitive style, it may be part of the cognitive manifestation of BAS dysregulation and may underlie a cognitive deficit in how patients feel about their bodies. Indeed, the above explanations of low self-esteem as implicated in the onset, clinical manifes tation, and subsyndromal symptomatology of BD may all be accounted for by a more fundamental vulnerability such as BAS dysregulation.
Body Image in Schizophrenia The DSM-IV-TR uses the term ‘psychotic’ to refer to delusions, prominent hallucinations, disorganized speech, as well as dis organized or catatonic behavior. While psychosis can occur in
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many psychiatric and medical conditions, the final sections of this article will focus its discussion on body image in two psychotic disorders: schizophrenia and delusional disorder. Schizophrenia is a disorder characterized by active-phase symptoms (i.e., two or more of the following: delusions, hal lucinations, disorganized speech, grossly disorganized or catatonic behavior, negative symptoms). Two or more of these symptoms must be present for four consecutive weeks and must be present in some form for a duration of at least 6 months. With respect to body image, the DSM-IV states that “deper sonalization, derealization, and somatic concerns may occur and sometimes reach delusional proportions.” Depersonalization refers to “an alteration in perception or experience of the self so that one feels detached from, and as if one is an outside observer of, one’s mental processes or body (e.g., feeling like one is in a dream).” Derealization is “an alteration in the perception or experience of the external world so that it seems strange or unreal (e.g., people may seem unfamiliar or mechanical).” Ever since Bleuler introduced the term schizophrenia in 1911, disturbances of ego, self-concept, and body image have been regarded as central in the psychopathology of the disor der. Prior to the 1980s, the field limited its examination of body image in schizophrenia to the content of their delusions and hallucinations. For example, in the mid-twentieth century, Bender and Keeler found, through experimental techniques, that schizophrenic children have particular difficulty in deter mining the periphery of their bodies. As such, marked abnormal bodily sensations tend to simply be lumped under the more general classification of somatic hallucinations or delusional perception. This simplification often leads to a diag nosis of paranoid schizophrenia in these patients experiencing marked abnormal bodily sensations. It is unknown how many patients diagnosed with paranoid schizophrenia would be more precisely described by a diagnosis of cenesthetic schizo phrenia. It is likewise uncertain what the clinical implications of such reclassification would be. Current data continue to support the notion that, more than simply depersonalization, patients with schizophrenia may have a distorted sense of actual physical boundaries. This dis torted view can manifest in numerous ways. One patient may feel that a limb does not belong to him, whereas another may feel a kind of ‘oneness’ with his environment. A common observation with respect to body image pathology in schizo phrenic patients is abnormal estimation of lower extremity length and size. Patients’ underestimation of the lower extre mities has been found to be moderately associated with a higher degree of anxiety symptoms and overestimation with increased grandiosity. More recently, the scope of study of somatic concerns in schizophrenia has broadened and now includes the study of the neurocognitive aspects and negative symptoms. In accor dance with this reconceptualization of the disorder, the descriptions of body image disturbance in schizophrenia have broadened to include such diverse phenomena as disruption of pain perception, out-of-body experiences, body dysmorphic symptoms, and self-injury. In 1997, Guimón reviewed body image disturbances in schizophrenia, including experiences of body deterioration, depersonalization, body boundary dis integration, and altered feelings of masculinity and femininity.
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He describes a range of body image perceptions and beliefs pertaining to missing or misshapen body parts, perceptions of the body as unusually weak or strong, changes in body size or consistency (e.g., turning into stone), denial of the existence of body parts, reports of body parts being replaced with those of another person, failure to recognize oneself in mirror reflec tions, and modifications of internal organs. He also reported on some patients who believe they see a replica of their body projected in front of them. Such abnormalities of body image, as well as depersonali zation, appear to be particularly common in those persons with the paranoid subtype of schizophrenia. However, it is uncertain whether the clinical features of the paranoid subtype adequately describe the schizophrenic patients with these dis turbances in body image. Despite the prominence of body image disturbances in schizophrenia, there is a lack of systematic investigation of body-focused symptoms in schizophrenia. The existing research provides inconsistent findings and many of these stu dies have suffered from significant methodological issues. Common flaws in methodology include poor specification of body image pathology, lack of diagnostic homogeneity, and use of nonstandardized measures. For example, some studies report perceptions of increased body size, while others report decreases. More fundamentally, it is unclear whether body image distortions result from conceptual aberrations or from dysfunction in processing sensory information. If the latter is true, there is nothing distinct about body distortion in schizo phrenia. That is, it may simply be another manifestation of the various perceptual distortions that persons with schizophrenia experience. Experts suggest that the internal monitoring of one’s own actions is disrupted in patients with schizophrenia. This abnormality may underlie positive symptoms of schizo phrenia in which self-generated actions are incorrectly attributed to an external agent (e.g., “That clock is making my arm rotate.”). In support of this, a recent functional magnetic resonance imaging (fMRI) study conducted on schizophrenia patients revealed impaired activation in the supragenual ante rior cingulate cortex during a performance monitoring task.
Body Image in Delusional Disorder Delusional disorder is characterized by the presence of nonbizarre delusions in the absence of other mood or psychotic symptoms. The DSM-IV-TR defines delusional disorder as a group of conditions in which the central feature is the presence of nonbizarre delusions for at least 1 month in duration. Apart from the impact of the delusion(s) or its ramifications, func tioning is not markedly impaired and criteria for schizophrenia are not met. Delusional disorder is divided into subtypes based on the predominant delusional theme (e.g., erotomanic, jea lous, grandiose). The DSM-IV-TR estimates that the population prevalence of delusional disorder is around 0.03%. Most stu dies suggest that the disorder accounts for 1–2% of admissions to mental health facilities. In somatic-type delusional disorder, the person has a delu sion that something is wrong with his or her body. Thus, somatic-type delusional disorder involves a fundamental dis turbance in body image. However, the existing literature on
delusional disorder does not address body image in delusional disorder beyond the content of the delusions. Delusions in somatic-type delusional disorder must involve bodily functions or sensations. They may be accompanied by prominent tactile or olfactory hallucinations related to the delusional theme. Common somatic delusions are that the person is infested by insects or parasites, that he or she is emitting a foul odor, that parts of the body are not functioning, or that certain parts of the body are misshapen and ugly even in the absence of objective evidence. The most common somatic delusion is the delusion of being infested. This condition is known by many names includ ing delusional infestation, delusional parasitosis, Ekbom’s syndrome, and formication. An online community of patients embrace the term ‘Morgellons disease’, to describe the condi tion as an unexplained infectious dermopathy. Patients present complaining of abnormal sensations as if infectious agents evoke them. They may report feeling parasites crawling under the skin, biting, leaving marks, and building nests. These indi viduals may inflict significant self-harm. For example, one case report describes a woman who decided to asphyxiate the bugs by covering her body with gasoline, leaving her with severe chemical burns. Another common somatic delusion is the belief that one emits a foul or offensive body odor which is not perceived by others. This condition is known as olfactory reference syn drome. Patients often believe that others take special notice of the odor in a negative way. Many patients perform repetitive behaviors, such as smelling themselves, showering excessively, and/or attempting to mask the odor with perfumes. The con dition commonly leads to social avoidance and isolation. Some patients have reported staying completely housebound for at least a week, and depression is often comorbid. Since delusions can be of such varied content and quality, they are often difficult to evaluate clinically. A vast number of medical conditions are associated with the development of delusions. These include neurodegenerative disorders, other central nervous system disorders, vascular disease, infectious disease, metabolic disorders, endocrinopathies, and vitamin deficiencies. Delusions are also associated with toxin exposure, and with the use and withdrawal from medications and other substances. For example, cocaine use is associated with delu sions of parasitosis, or ‘coke bugs’. Such a substance-induced psychotic disorder may appear identical in symptomatology to delusional disorder. Despite the fact that somatic-type delusional disorder is sometimes also called monosymptomatic hypochondriacal psy chosis, it is different from hypochondriasis. Hypochondriacs can entertain the possibility that the feared disease is not present. In contrast, people with somatic-type delusional disorder are com pletely convinced of the physical basis of their complaints. Therefore, delusional intensity differentiates delusional disorder from hypochondriasis. Delusions can also be seen in body dysmorphic disorder. There is a scarcity of scientific data on delusional disorder, with most of the literature consisting of individual case descrip tions and small, uncontrolled case studies. Furthermore, psychiatrists likely underestimate the prevalence, because people with delusional disorder will rarely seek or accept psy chiatric care. Individuals with somatic-type delusional disorder
Body Image in Mood and Psychotic Disorders are more likely to present to internists, dermatologists, infec tious disease specialists, dentists, and gastroenterologists. The etiology of delusional disorder is unknown and is difficult to determine. However, current data provide some clues into possible genetic, biochemical, neurological, and psy chological factors in the development of delusional disorder. Concerning genetic factors in delusional disorder, patterns of familial inheritance suggest that delusional disorder is not linked to a familial propensity to schizophrenia. Rather, delu sional disorder may be associated with a predisposition to paranoid personality disorder. Concerning biochemical corre lates of delusional disorder, hyperdopaminergic states have been implicated in the development of delusions. Likewise, treatment with a dopamine antagonist has been associated with symptom improvement. Concerning the neurobiology of somatic delusions, somatic delusions have been associated with alterations in regional cerebral blood flow, particularly to areas involved in somatic sensory processing. With respect to psychological explanations of delusional disorder, several models of cognitive function in delusional disorder have been proposed but not proven or validated. Delusional disorder is difficult to treat, as patients frequently deny that they have any psychological problem. However, delusional disorder may respond well to treatment to the point of remission. A review of 224 case reports found that delusional disorders were fairly responsive to treatment: 50% of patients reported symptom-free recovery and 90% of patients showed at least some improvement. The treatment of delusional disorder can include psycho pharmacological therapy and psychotherapy. Existing recommendations are mostly based on data from case series, since there is a paucity of systematically conducted studies. The treatment of somatic-type delusional disorder with medication usually involves the use of atypical or typical antipsychotic agents. There is a substantial older literature on the use of pimozide (a unique typical antipsychotic agent) in the treat ment of monosymptomatic delusional hypochondriasis, which, again, is equivalent to somatic-type delusional disorder. In contrast, treatment of patients with body dysmorphic disorder who have poor insight or delusional conviction usually involves the use of selective serotonin reuptake inhibi tors, including fluoxetine and fluvoxamine, where improvement in obsessive preoccupation corresponds with improvement in delusional certainty. This suggests that the delusional preoccupation in BDD is part of the obsessive pre occupation, and this is one of the very specific circumstances in which delusional symptoms respond to antidepressant rather than antipsychotic agents. Commonly, patients with delusional disorder receive a combination of antipsychotic and antidepressant medication, as well as other interventions such as cognitive behavioral therapy. One review found no significant difference in the efficacy of one antipsychotic over another. Somatic delusions
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in particular seemed more responsive to antipsychotic therapy than other types of delusions. However, this apparent differ ence may result mostly from the poor response rates in the treatment of persecutory delusions.
Conclusions As the distinction between mind and body fades even in Western medicine, it should come as no surprise that ‘mental’ illness often involves a disturbance in how one views one’s physical body. It is clear that body image disturbance may play an integral role in several psychiatric diagnoses including depression, BD, schizophrenia, and somatic delusional disorder. Although the precise frequency, extent, and etiology of body image pathology in these disorders are unknown, imaging and neurobiological investigation are permitting new insights. Overall, it seems that body image disturbance may simply be one outlet for psychiatric symptomatology to become manifest.
See also: Body Dysmorphic Disorder; Body Image and Personality; Body Image and Self-Esteem; Body Image in Social Contexts; Cognitive-Behavioral Perspectives on Body Image; Psychodynamic Perspectives on Body Image; Neuroscientific Perspectives on Body Image.
Further Reading American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders: Text Revision (DSM-IV-TR), 4th ed. Arlington, VA: American Psychiatric Association. Atlantis, E., and Ball, K. (2008). Association between weight perception and psychological distress. International Journal of Obesity 32, 715–721. Cash, T. F., Phillips, K. A., Santos, M. T., and Hrabosky, J. I. (2004). Measuring “negative body image”: Validation of the body image disturbance questionnaire in a non-clinical population. Body Image: An International Journal of Research 1, 363–372. Freudenmann, R. W., and Lepping, P. (2009). Delusional infestation. Clinical Microbiology Reviews 22, 690–732. Manschreck, T. C. (1996). Delusional disorder: The recognition and management of paranoia. Journal of Clinical Psychiatry 57(supplement 3), 32–38; discussion 49. McGilchrist, I., and Cutting, J. (1995). Somatic delusions in schizophrenia and the affective psychoses. British Journal of Psychiatry 167, 350–361. Noles, S. W., Cash, T. F., and Winstead, B. A. (1985). Body image, physical attractiveness, and depression. Journal of Consulting and Clinical Psychology 53, 88–94. Pruzinsky, T. (2002). Body image disturbances in psychotic disorders. In: Cash, T. F., and Pruzinsky, T. (eds.) Body Image: A Handbook of Theory, Research, and Clinical Practice, pp. 322–329. New York: Guilford Press. Stice, E., and Bearman, S. K. (2001). Body image and eating disturbances prospectively predict growth in depressive symptoms in adolescent girls: A growth curve analysis. Developmental Psychology 37, 597–607. Wiebking, C., Bauer, A., de Greck, M., et al. (2010). Abnormal body perception and neural activity in the insula in depression: An fMRI study of the depressed “material me”. The World Journal of Biological Psychiatry 11, 538–549.
Glossary catatonia Characterized by either rigidity or extreme laxness of limbs. cenesthesia The general feeling of inhabiting one’s body that arises from multiple stimuli from various bodily organs. hypothalamic–pituitary–adrenocortical (HPA) axis Complex set of direct influences and feedback interactions among the hypothalamus, the pituitary gland (a pea-shaped structure located above the hypothalamus), and the adrenal glands (located on top of each kidney) that controls reactions to stress and regulates many bodily processes such as
Introduction
Body Image and Major Depressive Disorder
This article describes body image disturbances in mood and psychotic disorders, focusing specifically on four diagnoses: major depressive disorder (MDD), bipolar disorder (BD), schi zophrenia, and somatic-type delusional disorder. For each of these diagnoses, we explore clinical symptomatology and the extent to which body image plays a role in the course of illness. Even though body image may be integral to the phenomenol ogy of these disorders, relatively little is known about the underlying mechanisms of body image pathology in each of them.
Body Image and Depression Body Image and Depressive Symptoms in Nonclinical Samples The causal relationship between poor body image and depres sive symptomatology is still largely unclear. While some consider body image distortion to be among the cognitive symptoms of depression, others sidestep causality and are only comfortable noting the association between depressed subjects and aesthetic dissatisfaction. Although the causal directionality has yet to be fully elucidated, prospective studies have indicated that body image dissatisfaction is an important precursor or risk for depression. Each person, to some extent, is concerned with their appearance – how they present themselves to the world. Some may feel they are too chubby, or that their hair is too thin, or their complexion is imperfect. Yet much of the basis for developing validated scales of body image assessment is predicated upon the fact that body image disturbance involves a triad of dissatisfaction, distress (or dysphoria), and dysfunction (or impairment). In other words, in subjects in whom body image becomes pathological, the degree of concern, mental preoccupation, and emotional distress are significant enough to interfere with social and occupational functioning. Encyclopedia of Body Image and Human Appearance, Volume 1
digestion, immune function, energy storage, and expenditure. insula A portion of the cerebral cortex involved in diverse functions such as consciousness, emotions, and interpersonal experience. polymorphism A particular point mutation in genotype that leads to a unique phenotype. prefrontal cortex Anterior part of the frontal lobes of the brain that is responsible for executive function (planning complex cognitive behaviors and decision making). visceral hypersensitivity A condition wherein pressure and sensation that is normally not painful or not perceived is felt as intense pain.
The core symptom of MDD is depressed mood or loss of interest in activity that is present most of the day nearly every day for at least 14 days. Common symptoms include insomnia or hyper somnia, psychomotor agitation or retardation, recurrent thoughts of death, and diminished ability to think and concentrate. MDD has a lifetime prevalence of approximately 15% and may be as high as 25% for women. The course of MDD is variable. Some people have isolated episodes that are separated by years without any depressive symptoms. Others have a cluster of episodes or increasingly frequent episodes as they age. Episodes of MDD often follow a severe or significant life stressor, such as death of a loved one or divorce. MDD is associated with a 1.5–3.0 times increased likelihood of having a first-degree biological relative with the disorder. The Diagnostic and Statistical Manual of Mental Disorders: Text Revision, 4th edition (DSM-IV-TR) lists several specifiers to further classify the diagnosis. MDD ‘severe with psychotic features’ often signals the presence of delusions or hallucina tions and is further subdivided into mood-congruent or mood-incongruent psychotic features. The former category is characterized by delusions or hallucinations whose content is entirely consistent with typical depressive themes of personal inadequacy, guilt, death, and so on. Presumably, this subdivi sion of MDD is most likely to include distortions of body image. Patients may see themselves as misshapen, ugly, or physically deformed, which is consistent with general feelings of inadequacy. The degree to which MDD patients with promi nent body image disturbance actually receive this specific diagnosis has yet to be studied. Patients with MDD can be characterized by alterations in mood, cognition, perception, sensation, and behavior, all of which may impact their bodies and body image. Their emo tions and cognitions tend toward ruminations, self-blame, and increased association of their self with negative emotions. Their behavior is often characterized by persistent somatovegetative symptoms. At the same time, their altered sensation and
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perception may manifest itself as apparent hyperawareness of bodily changes. Interestingly, patients with traits of anxiety and depression have been found to have a decreased pain tolerance and demonstrate a kind of visceral hypersensitivity or intero ceptive awareness. It seems that depressed patients may actually ‘feel more’ in a literal sense. The connection between anxious/depressive traits and visceral hypersensitivity has been extensively studied in irritable bowel syndrome. One hypothe sized mechanism for the condition suggests that end-organ sensitivity (via nociceptors), endogenous modulation (involving the cerebral cortex and brain stem), spinal hyperex citability (via nitric oxide activation), and long-term hyperalgesia interact in such a way as to disrupt the enteric nervous system and thereby alter bowel function. Mood and self-esteem are related to one’s perception of and satisfaction with one’s body. Research supports the link between poor body image and higher incidence of depression and depressive symptomatology. Patients suffering from major depression report less favorable evaluations of their physical aesthetics. They often feel that their entire bodies, or specific features, are ugly, unattractive, and unappealing. Evidence also suggests that low self-esteem (which is moderately correlated with body image dissatisfaction) is a premorbid predictor of depression. Low self-esteem also persists during euthymic phases of MDD. In the case of MDD, a poor body image associated with low self-esteem is usually mood congruent, or consistent with overall feelings of low self-worth. The results of some studies have shown that body image disturbance is asso ciated with depression, while other studies suggest that depression simply predisposes individuals to body image dis turbance. Interestingly, depression is related to the subjective assessment of one’s own physical attractiveness, but not neces sarily to observer-rated physical attractiveness. That is, depressed persons are more likely to think they are unattractive despite how they are perceived by others. This is consistent with research showing that nondepressed subjects display more positive distortions of self-directed social events as well as more positive distortions of control over environmental events. Imaging studies of patients with MDD have indicated an association between emotional and cognitive abnormalities and altered neural activity in the medial cortical regions, parti cularly the dorsomedial prefrontal cortex, which is believed to be central to emotional regulation. However, the neural correlates of abnormal somatovegetative symptoms and inter oceptive awareness in MDD remain unclear. Recently, a relationship between abnormal body perception and reduced activity within the anterior insula has been identified. The anterior insula is a region that has been linked to interoceptive awareness of stimuli such as heartbeat, gastric distension, and pain. Generally, delusional thought processes are associated with conditions that affect the limbic system and basal ganglia – regions that are also highly implicated in the pathophysiology of depression. The limbic system is involved in a variety of functions including emotion, behavior, long-term memory, and olfaction. The basal ganglia are also associated with a variety of functions including motor control and learning. Existing data fail to adequately address the question of whether patients with poor body image can be considered to be in a constant state of emotional distress. Surmising that this is the case, this would have far-reaching implications in terms of the physiological consequences of poor body image. Stress
has been shown to be one of the most potent triggers of depression. In animal models, external stressors cause serotonin dysregulation, leading to decreased brain monoami nergic activity and the state of depression. External stressors likely interact with genetic variations (such as specific serotonin transporter gene polymorphisms) to produce the wide variability in the clinical presentation of MDD. The stress-related alterations in the central nervous system in turn activate two neuroendocrine pathways called the hypothalamic–pituitary–adrenocortical (HPA) axis and the sympathetic–adrenomedullary (SA) system. Persistent HPA and SA activation can lead to downstream abnormalities in certain physiological processes such as platelet function, auto nomic tone, inflammation, and endothelial function. Poor or distorted body image, via emotional stress and its negative effects on various physiological processes, may be related to poor health outcomes (e.g., cardiovascular disease). These pathways may help explain the increased incidence of certain medical conditions among depressed patients. One meta-analysis concluded that depressed patients are three times more likely to be noncompliant with medical treatment recommendations. Thus, treatment of depression pharmacolo gically and/or psychotherapeutically may improve patients’ depressive symptoms, body image, and overall physiological health. The extent to which patients with MDD and mood-congruent body image concerns have improvement in body image upon successful treatment of depression is cur rently not fully known.
Body Image in Bipolar Disorder The BDs include bipolar I disorder, bipolar II disorder, cyclothymia, and BD not otherwise specified. The discussion here will focus on bipolar I disorder, which has a worldwide prevalence of 3–5%. The essential feature of bipolar I disorder is a clinical course that includes the occurrence of one or more manic episodes or mixed episodes. According to the DSM IV-TR, a manic episode is defined as a distinct period of abnor mally or persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary). Some of the criteria for a manic episode listed in the DSM-IV-TR may include body image aberrations such as inflated self-esteem or hypersexual behavior. For a mixed epi sode, criteria for a manic episode and for a major depressive episode (except duration) are met nearly every day for at least 1 week. BD most often starts with depression (75% of the time for women, 67% for men). Most patients experience both depressive and manic episodes, although 10–20% experience only manic episodes. In mania or hypomania (manic symptoms that are clini cally significant but insufficient to cause social/occupational impairment), patients may display an enhanced or inflated sense of body image, such that one may feel especially attrac tive or sexual. As unstable mood is an integral part of BD, patients may have fluctuating perceptions of their body image. Generally, it seems that the higher the degree of fluctua tion in self-esteem, the worse the prognosis in patients with BD. One study measured self-esteem daily over a 1-week period and found that BD patients had more fluctuations in self-esteem compared to MDD patients and controls. Similarly, studies
Body Image in Mood and Psychotic Disorders have found that cyclothymic temperament, which entails con tinuous shifts in mood and perception as well as variations in self-esteem, is more severe in BD patients than in MDD patients or controls. Unstable self-esteem, in combination with unrea listic standards of success, may predispose individuals with BD toward extreme shifts in self-evaluation, which may include appraisal of one’s physical attributes (i.e., body image). Low self-esteem is believed to be a risk factor contributing to the onset of BD in genetically vulnerable individuals. An early manifestation of low self-esteem in BD was indicated by a study in which adolescents with BD were found to have lower self-esteem than adolescent controls. This may be related to the relatively high incidence of childhood traumas (e.g., sexual or physical abuse) reported by BD patients (one study found more than a 50% incidence of traumatic events in youth with diagnosed BD). Another explanation, which is referred to as the complication or scar hypothesis, is that low self-esteem is a consequence of BD. As widely documented, many BD patients experience a number of impairments due to the illness, such as cognitive deficits and occupational and social difficulties, which may contribute to the development and maintenance of low self-esteem. Living with BD may also disrupt identity formation. BD patients often have difficulty in establishing a coherent identity due to their changing and contrasting mood episodes. Conversely, disruption of identity formation may worsen the experience of BD. That is, an unstable self-image may cause unpredictable behaviors and interpersonal conflicts. These negative experiences in turn may damage self-esteem and dar ken perceptions of one’s self and body image. Thus, the relationship may be cyclical. BD may also give rise to low self-esteem through the negative stigma attached to the illness. One study found that awareness of stigmatization was corre lated with lower self-esteem in remitted BD patients. A multimodal theory explains BD as a specific dysregulation of the behavioral activation system (BAS), a system involved in behavioral and neurological responses to cues signaling oppor tunities to achieve or lose rewards. According to the expanded version of this theory, high and low BAS activation can lead to mania and depression, respectively, depending on the type of eliciting events and how they are appraised in terms of rele vance and efficacy. Research points to a specific BAS-related cognitive style in BD characterized by performance evaluation, autonomy, self-criticism, and an emphasis on goal attainment. This can manifest in some BD patients as a futile (and frustrat ing) quest for physical and cosmetic perfection (skin, weight, etc.). Since low self-esteem seems to fit thematically into such a cognitive style, it may be part of the cognitive manifestation of BAS dysregulation and may underlie a cognitive deficit in how patients feel about their bodies. Indeed, the above explanations of low self-esteem as implicated in the onset, clinical manifes tation, and subsyndromal symptomatology of BD may all be accounted for by a more fundamental vulnerability such as BAS dysregulation.
Body Image in Schizophrenia The DSM-IV-TR uses the term ‘psychotic’ to refer to delusions, prominent hallucinations, disorganized speech, as well as dis organized or catatonic behavior. While psychosis can occur in
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many psychiatric and medical conditions, the final sections of this article will focus its discussion on body image in two psychotic disorders: schizophrenia and delusional disorder. Schizophrenia is a disorder characterized by active-phase symptoms (i.e., two or more of the following: delusions, hal lucinations, disorganized speech, grossly disorganized or catatonic behavior, negative symptoms). Two or more of these symptoms must be present for four consecutive weeks and must be present in some form for a duration of at least 6 months. With respect to body image, the DSM-IV states that “deper sonalization, derealization, and somatic concerns may occur and sometimes reach delusional proportions.” Depersonalization refers to “an alteration in perception or experience of the self so that one feels detached from, and as if one is an outside observer of, one’s mental processes or body (e.g., feeling like one is in a dream).” Derealization is “an alteration in the perception or experience of the external world so that it seems strange or unreal (e.g., people may seem unfamiliar or mechanical).” Ever since Bleuler introduced the term schizophrenia in 1911, disturbances of ego, self-concept, and body image have been regarded as central in the psychopathology of the disor der. Prior to the 1980s, the field limited its examination of body image in schizophrenia to the content of their delusions and hallucinations. For example, in the mid-twentieth century, Bender and Keeler found, through experimental techniques, that schizophrenic children have particular difficulty in deter mining the periphery of their bodies. As such, marked abnormal bodily sensations tend to simply be lumped under the more general classification of somatic hallucinations or delusional perception. This simplification often leads to a diag nosis of paranoid schizophrenia in these patients experiencing marked abnormal bodily sensations. It is unknown how many patients diagnosed with paranoid schizophrenia would be more precisely described by a diagnosis of cenesthetic schizo phrenia. It is likewise uncertain what the clinical implications of such reclassification would be. Current data continue to support the notion that, more than simply depersonalization, patients with schizophrenia may have a distorted sense of actual physical boundaries. This dis torted view can manifest in numerous ways. One patient may feel that a limb does not belong to him, whereas another may feel a kind of ‘oneness’ with his environment. A common observation with respect to body image pathology in schizo phrenic patients is abnormal estimation of lower extremity length and size. Patients’ underestimation of the lower extre mities has been found to be moderately associated with a higher degree of anxiety symptoms and overestimation with increased grandiosity. More recently, the scope of study of somatic concerns in schizophrenia has broadened and now includes the study of the neurocognitive aspects and negative symptoms. In accor dance with this reconceptualization of the disorder, the descriptions of body image disturbance in schizophrenia have broadened to include such diverse phenomena as disruption of pain perception, out-of-body experiences, body dysmorphic symptoms, and self-injury. In 1997, Guimón reviewed body image disturbances in schizophrenia, including experiences of body deterioration, depersonalization, body boundary dis integration, and altered feelings of masculinity and femininity.
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He describes a range of body image perceptions and beliefs pertaining to missing or misshapen body parts, perceptions of the body as unusually weak or strong, changes in body size or consistency (e.g., turning into stone), denial of the existence of body parts, reports of body parts being replaced with those of another person, failure to recognize oneself in mirror reflec tions, and modifications of internal organs. He also reported on some patients who believe they see a replica of their body projected in front of them. Such abnormalities of body image, as well as depersonali zation, appear to be particularly common in those persons with the paranoid subtype of schizophrenia. However, it is uncertain whether the clinical features of the paranoid subtype adequately describe the schizophrenic patients with these dis turbances in body image. Despite the prominence of body image disturbances in schizophrenia, there is a lack of systematic investigation of body-focused symptoms in schizophrenia. The existing research provides inconsistent findings and many of these stu dies have suffered from significant methodological issues. Common flaws in methodology include poor specification of body image pathology, lack of diagnostic homogeneity, and use of nonstandardized measures. For example, some studies report perceptions of increased body size, while others report decreases. More fundamentally, it is unclear whether body image distortions result from conceptual aberrations or from dysfunction in processing sensory information. If the latter is true, there is nothing distinct about body distortion in schizo phrenia. That is, it may simply be another manifestation of the various perceptual distortions that persons with schizophrenia experience. Experts suggest that the internal monitoring of one’s own actions is disrupted in patients with schizophrenia. This abnormality may underlie positive symptoms of schizo phrenia in which self-generated actions are incorrectly attributed to an external agent (e.g., “That clock is making my arm rotate.”). In support of this, a recent functional magnetic resonance imaging (fMRI) study conducted on schizophrenia patients revealed impaired activation in the supragenual ante rior cingulate cortex during a performance monitoring task.
Body Image in Delusional Disorder Delusional disorder is characterized by the presence of nonbizarre delusions in the absence of other mood or psychotic symptoms. The DSM-IV-TR defines delusional disorder as a group of conditions in which the central feature is the presence of nonbizarre delusions for at least 1 month in duration. Apart from the impact of the delusion(s) or its ramifications, func tioning is not markedly impaired and criteria for schizophrenia are not met. Delusional disorder is divided into subtypes based on the predominant delusional theme (e.g., erotomanic, jea lous, grandiose). The DSM-IV-TR estimates that the population prevalence of delusional disorder is around 0.03%. Most stu dies suggest that the disorder accounts for 1–2% of admissions to mental health facilities. In somatic-type delusional disorder, the person has a delu sion that something is wrong with his or her body. Thus, somatic-type delusional disorder involves a fundamental dis turbance in body image. However, the existing literature on
delusional disorder does not address body image in delusional disorder beyond the content of the delusions. Delusions in somatic-type delusional disorder must involve bodily functions or sensations. They may be accompanied by prominent tactile or olfactory hallucinations related to the delusional theme. Common somatic delusions are that the person is infested by insects or parasites, that he or she is emitting a foul odor, that parts of the body are not functioning, or that certain parts of the body are misshapen and ugly even in the absence of objective evidence. The most common somatic delusion is the delusion of being infested. This condition is known by many names includ ing delusional infestation, delusional parasitosis, Ekbom’s syndrome, and formication. An online community of patients embrace the term ‘Morgellons disease’, to describe the condi tion as an unexplained infectious dermopathy. Patients present complaining of abnormal sensations as if infectious agents evoke them. They may report feeling parasites crawling under the skin, biting, leaving marks, and building nests. These indi viduals may inflict significant self-harm. For example, one case report describes a woman who decided to asphyxiate the bugs by covering her body with gasoline, leaving her with severe chemical burns. Another common somatic delusion is the belief that one emits a foul or offensive body odor which is not perceived by others. This condition is known as olfactory reference syn drome. Patients often believe that others take special notice of the odor in a negative way. Many patients perform repetitive behaviors, such as smelling themselves, showering excessively, and/or attempting to mask the odor with perfumes. The con dition commonly leads to social avoidance and isolation. Some patients have reported staying completely housebound for at least a week, and depression is often comorbid. Since delusions can be of such varied content and quality, they are often difficult to evaluate clinically. A vast number of medical conditions are associated with the development of delusions. These include neurodegenerative disorders, other central nervous system disorders, vascular disease, infectious disease, metabolic disorders, endocrinopathies, and vitamin deficiencies. Delusions are also associated with toxin exposure, and with the use and withdrawal from medications and other substances. For example, cocaine use is associated with delu sions of parasitosis, or ‘coke bugs’. Such a substance-induced psychotic disorder may appear identical in symptomatology to delusional disorder. Despite the fact that somatic-type delusional disorder is sometimes also called monosymptomatic hypochondriacal psy chosis, it is different from hypochondriasis. Hypochondriacs can entertain the possibility that the feared disease is not present. In contrast, people with somatic-type delusional disorder are com pletely convinced of the physical basis of their complaints. Therefore, delusional intensity differentiates delusional disorder from hypochondriasis. Delusions can also be seen in body dysmorphic disorder. There is a scarcity of scientific data on delusional disorder, with most of the literature consisting of individual case descrip tions and small, uncontrolled case studies. Furthermore, psychiatrists likely underestimate the prevalence, because people with delusional disorder will rarely seek or accept psy chiatric care. Individuals with somatic-type delusional disorder
Body Image in Mood and Psychotic Disorders are more likely to present to internists, dermatologists, infec tious disease specialists, dentists, and gastroenterologists. The etiology of delusional disorder is unknown and is difficult to determine. However, current data provide some clues into possible genetic, biochemical, neurological, and psy chological factors in the development of delusional disorder. Concerning genetic factors in delusional disorder, patterns of familial inheritance suggest that delusional disorder is not linked to a familial propensity to schizophrenia. Rather, delu sional disorder may be associated with a predisposition to paranoid personality disorder. Concerning biochemical corre lates of delusional disorder, hyperdopaminergic states have been implicated in the development of delusions. Likewise, treatment with a dopamine antagonist has been associated with symptom improvement. Concerning the neurobiology of somatic delusions, somatic delusions have been associated with alterations in regional cerebral blood flow, particularly to areas involved in somatic sensory processing. With respect to psychological explanations of delusional disorder, several models of cognitive function in delusional disorder have been proposed but not proven or validated. Delusional disorder is difficult to treat, as patients frequently deny that they have any psychological problem. However, delusional disorder may respond well to treatment to the point of remission. A review of 224 case reports found that delusional disorders were fairly responsive to treatment: 50% of patients reported symptom-free recovery and 90% of patients showed at least some improvement. The treatment of delusional disorder can include psycho pharmacological therapy and psychotherapy. Existing recommendations are mostly based on data from case series, since there is a paucity of systematically conducted studies. The treatment of somatic-type delusional disorder with medication usually involves the use of atypical or typical antipsychotic agents. There is a substantial older literature on the use of pimozide (a unique typical antipsychotic agent) in the treat ment of monosymptomatic delusional hypochondriasis, which, again, is equivalent to somatic-type delusional disorder. In contrast, treatment of patients with body dysmorphic disorder who have poor insight or delusional conviction usually involves the use of selective serotonin reuptake inhibi tors, including fluoxetine and fluvoxamine, where improvement in obsessive preoccupation corresponds with improvement in delusional certainty. This suggests that the delusional preoccupation in BDD is part of the obsessive pre occupation, and this is one of the very specific circumstances in which delusional symptoms respond to antidepressant rather than antipsychotic agents. Commonly, patients with delusional disorder receive a combination of antipsychotic and antidepressant medication, as well as other interventions such as cognitive behavioral therapy. One review found no significant difference in the efficacy of one antipsychotic over another. Somatic delusions
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in particular seemed more responsive to antipsychotic therapy than other types of delusions. However, this apparent differ ence may result mostly from the poor response rates in the treatment of persecutory delusions.
Conclusions As the distinction between mind and body fades even in Western medicine, it should come as no surprise that ‘mental’ illness often involves a disturbance in how one views one’s physical body. It is clear that body image disturbance may play an integral role in several psychiatric diagnoses including depression, BD, schizophrenia, and somatic delusional disorder. Although the precise frequency, extent, and etiology of body image pathology in these disorders are unknown, imaging and neurobiological investigation are permitting new insights. Overall, it seems that body image disturbance may simply be one outlet for psychiatric symptomatology to become manifest.
See also: Body Dysmorphic Disorder; Body Image and Personality; Body Image and Self-Esteem; Body Image in Social Contexts; Cognitive-Behavioral Perspectives on Body Image; Psychodynamic Perspectives on Body Image; Neuroscientific Perspectives on Body Image.
Further Reading American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders: Text Revision (DSM-IV-TR), 4th ed. Arlington, VA: American Psychiatric Association. Atlantis, E., and Ball, K. (2008). Association between weight perception and psychological distress. International Journal of Obesity 32, 715–721. Cash, T. F., Phillips, K. A., Santos, M. T., and Hrabosky, J. I. (2004). Measuring “negative body image”: Validation of the body image disturbance questionnaire in a non-clinical population. Body Image: An International Journal of Research 1, 363–372. Freudenmann, R. W., and Lepping, P. (2009). Delusional infestation. Clinical Microbiology Reviews 22, 690–732. Manschreck, T. C. (1996). Delusional disorder: The recognition and management of paranoia. Journal of Clinical Psychiatry 57(supplement 3), 32–38; discussion 49. McGilchrist, I., and Cutting, J. (1995). Somatic delusions in schizophrenia and the affective psychoses. British Journal of Psychiatry 167, 350–361. Noles, S. W., Cash, T. F., and Winstead, B. A. (1985). Body image, physical attractiveness, and depression. Journal of Consulting and Clinical Psychology 53, 88–94. Pruzinsky, T. (2002). Body image disturbances in psychotic disorders. In: Cash, T. F., and Pruzinsky, T. (eds.) Body Image: A Handbook of Theory, Research, and Clinical Practice, pp. 322–329. New York: Guilford Press. Stice, E., and Bearman, S. K. (2001). Body image and eating disturbances prospectively predict growth in depressive symptoms in adolescent girls: A growth curve analysis. Developmental Psychology 37, 597–607. Wiebking, C., Bauer, A., de Greck, M., et al. (2010). Abnormal body perception and neural activity in the insula in depression: An fMRI study of the depressed “material me”. The World Journal of Biological Psychiatry 11, 538–549.