- Email: [email protected]
What is body image?
Behao. Res.
Pergamon
0005-7967(94)EOOO9-8
Thu. Vol. 32, No. 5, pp. 497-502, 1994 ElsrvierScienceLtd Printedin Great Britain 0005-7967/94 $7.00 + 0.00
INVITED ESSAY WHAT
IS BODY PETER DAVID
IMAGE?
SLADE
Department of Clinical Psychology, School of Health Sciences, Faculty of Medicine, The Whelan Building, P.O. Box 147, Liverpool L69 3BX, England (Received 21 December
1.
1993)
INTRODUCTION
The concept of ‘body image’ was first formulated as an important and integral psychological phenomenon by the German writer, Schilder, in his monograph The Image and Appearance of the Human Body, which was published in English in 1935. In his monograph Schilder spoke of body image as “the picture of our own body which we form in our mind, that is to say the way in which the body appears to ourselves”. In recent times the definition has been expanded to refer to “the picture we have in our minds of the size, shape and form of our bodies; and to our feelings concerning these characteristics and our constituent body parts” (Slade, 1988). That is, body image is viewed as having two main components, a ‘perceptual component’ and an ‘attitudinal component’. These correspond to the distinction that is often drawn between ‘body percept’ and ‘body concept’. Paralleling this conceptual distinction, a similar one is made practically in the experimental literature on eating and weight disorders, between techniques which are focused on the assessment of: (1) the accuracy of an individual’s body size estimation; and (2) the attitudes/feelings an individual has towards their own body. The former is viewed as a ‘perceptual’ judgement, while the latter is generally considered to reflect ‘attitudinal, affective and cognitive’ variables. The recent literature on ‘body image’ has been greatly influenced by applied clinical concerns. These involve three main areas. The first, and the most influential area, is that of specific ‘neurological disorders’ in which patients exhibit a faulty perception of their own body. For example, neglect syndromes in which patients fail to recognize a hemiplegia or respond to a part of their body as though it did not exist [see the review by Cumming (1988)]. The second area is that of body image distortion (BID) as observed in patients with either an eating disorder (i.e. anorexia nervosa and bulimia nervosa) or a weight disorder (i.e. obesity). As this is the area where the most systematic experimental work has been done, I shall be focusing on this research later. The final clinical area relates to a highly specific problem concerning body image concern, which is viewed as involving a delusional misperception, and is referred to as ‘body dysmorphophobia’. In all these areas the ‘misperception’ of body size and shape is the central concern. One effect of this amalgamation of problems from differing areas (particularly from neurological disorders) is to reinforce the notion that body image is primarily a perceptual phenomenon. In this essay I shall argue that body image is not a simple perceptual phenomenon and that, even when we set out to measure an individual’s perception of their own body, the judgements the individual makes are highly influenced by cognitive, affective, attitudinal and other variables. 2. EARLY
OBSERVATIONS
ON
BODY
IMAGE
IN
THE
EATING
DISORDERS
The pioneering observations in this area were made by Hilde Bruch in the early sixties (e.g. Bruch, 1962). She was struck by the adamant attitude of emaciated anorectic patients that their bodies were actually ‘fat’ and came to the opinion that this was a central and diagnostic feature 497
PETERDAVID SLADE
498
of the psychopathology of anorexia nervosa. Moreover, Bruch argued that this distorted body image was a “disturbance of delusional proportions”, with the implication that it was fixed and resistant to direct attempts at modification. The influential nature of the latter view has meant that there have been very few attempts at body image therapy with eating disorder Ss and, indeed, to date there have still been no published controlled trials of such an intervention. By contrast, there have been numerous attempts to test the basic thesis of Bruch that eating disorder Ss possess a distorted body image [see recent reviews by Cash & Brown (1987), Thompson (1990) and Slade & Brodie (1994)]. In the latter we analysed all the studies which had measured body size estimation accuracy and came to the following conclusions: (a) that individuals suffering from an eating disorder, whether anorexia or bulimia nervosa, do tend to overestimate their physical size (bodily widths); (b) that randomly selected female controls, and psychiatric groups, also overestimate their physical size, albeit to a lesser extent; and that (c) the tendency to overestimate physical size is neither unique to individuals suffering from an eating disorder, nor is it diagnostic. In our review (Slade & Brodie, 1994) we outlined five sets of recent observations which have led us to reformulate our views on the nature of BID in individuals suffering from an eating disorder. I shall briefly review these observations and the conclusions they led us to adopt. I shall then describe two other sets of observations which seem to me to be important in formulating a wider theory of the nature of body image. 3. RECENT
OBSERVATIONS
ON
BODY
IMAGE
IN THE
EATING
DISORDERS
(a) ‘Attitudinal bias’ ZIS‘perceptual inaccuracy’
A classic study was reported by Gardner and Moncrieff (1988), in which they used a signal detection approach to separate perceptual from attitudinal bias. They found no difference between 9 anorectic and 9 female control Ss in terms of sensory sensitivity but a significant difference in terms of bias. They concluded, therefore, that the body image judgement difference between the groups was primarily attitudinal in nature.
Following the early lead given by Crisp and Kallucy (1974), a series of recent studies have examined the effects of verbal instruction on body image accuracy judgements (Proctor & Morley, 1986; Franzen, Florin, Schneider & Meier, 1988; Bowden Touyz, Rodriguez, Hensley & Beumont, 1989; Robinson, Brodie, Dewey & Slade, 1994). All four of these studies have used experimental procedures and have compared the body image estimates of eating disorder Ss and controls under two main instructional conditions-‘cognitive’ (make your judgements according to how you THINK you look) and ‘affective’ (make your judgements according to how you FEEL you look). There is a remarkable consistency in the pattern of results across the studies. In all four studies eating disorder Ss exhibited significantly greater overestimation of body size in response to the ‘affective’ instructions compared to the ‘cognitive’ instructions; the controls were not affected by the differential instruction. Thus, the ‘instructional effect’ appears to be specific to eating disorder Ss. Moreover, in our study we retested Ss 1 week later and obtained the same result. The specificity of the ‘instructional effect’ appears to be both robust and reliable. (c) Variability in accuracy judgements
Unlike most studies in the field which report their findings in terms of average scores, Collins, Beumont, Touyz, Krass, Thompson and Philips (1987) decided to analyse their data in terms of the number of S’s falling into one of three accuracy bands. The bands were: accurate (i.e. within 14% of actual size); underestimation (i.e. 15% or more below actual size); and overestimation (i.e. 15% or more above actual size). They analysed data collected from four groups. The first group was a normal group (n = 60), of whom 80% fell within the accurate range and can therefore be characterized as accurate estimators. A second group were buiimics (n = 24), of whom 50% fell in the accurate range and a further 42% fell in the overestimation range. Thus, bulimics are either accurate estimators or are biased towards viewing themselves as being ‘fat’. By contrast with these two groups, the other two groups of obese (n = 150) and anorectic (n = 78) Ss had sizeable
What
is
499
body image?
percentages in each of the three categories of underestimation, accurate estimation and overestimation. For the obese these were 16, 52 and 32% respectively; while for the anorectics the percentages were 23,41 and 36%. The obese and anorectics were therefore more variable than the other groups, which is interesting because they are more likely to have had histories of repeated weight change. Such a history, I would suggest, may have the effect of loosening their ‘body image’ and thereby rendering them more liable to both overestimation and underestimation of body size.
(d) Efects of ‘mirror confrontation’ on body size estimation A study by Norris (1984) reported the size estimation accuracy judgements of four groups of Ss before and after a period of self mirror gazing. Neither the normal control group nor the emotional control group were affected by the manipulation; while both the bulimic and the anorectic groups showed a reduction in size estimation following the period of mirror confrontation. The manipulation produced change only in eating disorder Ss. (e) Evidence that anorectics exhibit fluctuating body size judgements Although the observation has been made by many clinical researchers in the field, it was left to Brindred, Bushnell, McKenzie and Wells (1990) to draw attention to the temporal instability of body size judgements of individual anorectic patients. Using the video method, the authors present size estimation data on 7 anorectics tested weekly over a 4-week period, from which they conclude “Although no consistent change over time in BID (body image distortion) was evident for the group overall, all subjects except one showed significant variations, albeit in different directions. This change in individuals, obscured in the analysis of grouped data, suggests a lack of stability of BID over time”. 4. RECONCEPTUALISATION
OF BODY IMAGE EATING DISORDERS
DISTORTION
(BID)
IN THE
Hilde Bruch viewed BID as a fixed and implacable feature of anorectics, which is of delusional proportions and therefore is NOT amenable to direct intervention. On the basis of the recent observations described above we have come to a different conclusion: “that individuals with eating disorders do NOT have a fixed, implacable distorted body image in the manner implied in Bruch’s writings; rather, they have an UNCERTAIN, UNSTABLE and WEAK body image; such that, when confronted by enthusiastic researchers and clinicians, they err on the side of caution and overestimate their body size”.
What important factors then lead eating disorder Ss, on average, to overestimate their body dimensions on size estimation tasks? In our recent review (Slade & Brodie, 1994) we suggested that the most likely explanation for such a bias is to be found in socio-cultural theories such as that of Garner, Garfinkel and Olmsted (1983). Socio-cultural theories suggest that the Zeitgeist among females in Western societies is towards a ‘thin body cult’ [see the review by McCarthy (1990)] and away from a higher body weight and obesity [see the review by Sobal & Stunkard (1989)]. Furthermore, these theories suggest that this desire for thinness is reflected in, and reinforced by, the media. There is now direct evidence starting to appear to support this proposition (e.g. Hamilton & Waller, 1993; Waller, Hamilton & Shaw, 1992). The latter have demonstrated that individuals suffering from an eating disorder exhibit a significant increase in their body size overestimation following exposure to magazine pictures of thin female models, while female controls are unaffected by a manipulation of this kind. Thus, social and cultural norms may have a specific and powerful effect on those individuals who go on to develop an eating disorder. We therefore propose the following mechanism for such an hypothetical effect: “That the cultural ideal in developed societies conveys the message that females should women, particularly those with a WEAK body image, respond to this message by judging consequently exhibit a marked tendency towards overestimation of body size or BID”.
5. OTHER
RELEVANT
be thin: and that young themselves to be fat and
OBSERVATIONS
In order to set the latter conclusions with respect to BID and eating disorders in a wider context, two other sets of observations are of direct interest. First, is the common observation concerning
PETERDAVID SLADE
500
the magnitude of judgements made on ‘ascending’ and ‘descending’ trials. With the sole exception of the image marking procedure of Askevold (1975) in all experimental methods for assessing size estimation accuracy, Ss are required to make their judgements of body size on ascending trials (where the comparison starts as thin and then becomes progressively fatter) and on descending trials (where the comparison starts as fat and then becomes progressively thinner). The common finding is that Ss produce much lower judgements on ascending as opposed to descending trials (e.g. Whitehouse, Freeman & Annandale, 1988; Gardner & Morrell, 1991; Brodie & Slade, 1988). A possible inte~retation of this common observation is that the mental representation that we have of the outline of our bodies is a loose one; and that this representation involves a body image ‘band’ (outline) which varies in width according to the past experience of the individual, the influence of social and cultural norms and the influence of a variety of individual factors. Another interesting and possibly important observation was made by Gardner and Morrell (1991) who found that obese Ss were more accurate in making judgements about their back than they were in judging their front. This suggests the possibility that repeated experience of viewing the body from one perspective (i.e. the front), particularly when the individual’s body may have been liable to substantial weight and bodily change over time, may have a distorting influence on body perception judgements. That is, fluctuating external sensory input, in combination with fluctuating internal input, may lead to an uncertain and distorted mental representation of the body. Certain tentative conclusions can be drawn from the above sets of observations, namely: (a) People have a mental representation of their bodies which is not fixed but rather takes a finite range (a body image band). (b) Given no particular emotional or attitudinal bias, the average judgement will be in the middle of the range (i.e. an accurate one). (c) Given a strong concern about personal body size, individuals will veer towards the outer extremities of the finite range (body image band), thus demonstrating BID. For such individuals this represents their ‘worst case scenario’. I shall now outline a general model of body image, conceived as a ‘loose mental representation of the body’, and the factors which appear to affect its development and manifestation. 6. TOWARDS
A MODEL
OF BODY
IMAGE
This essay is concerned with identifying the nature of body image. A general schematic model is presented in Fig. 1. This suggests that body image may be conceived as a ‘loose mental representation of the body’ which is influenced by at least seven sets of factors. Each of these will now be described briefly. (a) History of sensory input to body experience
Throughout the life span the individual receives sensory input of a visual, tactile and kinaesthetic nature on the form, size, shape and appearance of his/her body. The input is not static but varies over time and is viewed as shaping up the general ‘mental representation of the body’. @) History of wseightchange~~uctuation
The individuals who appear to have the most variable body image are anorectics and the obese. These are people who are most likely to have experienced major fluctuations in weight, the effect of which can be construed as loosening body image and leading to a broader ‘finite range/band’. (c) Culturai and social norms The fact of cultural differences in the prevalence of eating disorders has been well-established, as has the sex or social difference (McCarthy, 1990). In addition, recent evidence has established that eating disorder Ss are more prone to influence by exposure to media images of thin body types compared with non-eating disorder controls (Hamilton & Waller, 1993: Waller et al., 1992). Clearly some cultures (particularly Western ones) encourage the ‘thin body cult’ goal, especially for young females. This undoubtedly then serves to sharpen up individual attitudes to ideal body size and shape in selected subgroups in those societies.
What is body image?
Cotturaf
and Social
‘LowsIp!mental representation
501
Indiuidual weight
attitudes ta and shape
Cognitiue and affectiue variables
Fig. 1. A model of the factors influencing the development and manifestation of body image.
Cd) ~ndividuul uttit~des to weight and shqe
Studies in both the U.S.A. (Whitaker, Davies, ShaiTer, Johnson, Abrams, Walsh & Kalikow, 1989) and in the U.K. (Crisp, 1985) have found that 60-70% of 17-year-old females admit to dieting during the previous year, compared with only 20% of same-aged boys. Similarly, Whitaker et al. (1989) found that 84% of I7-year-aid girls ‘desired to lose weight’ compared with only 40% of boys of the same age. Thus, girls in Western societies are much more concerned than boys with conforming to the ‘thin body’ prescription: and this is especially so for certain subgroups, such as ballet dancers (Szmukler, Eisler, Gillies & Hayward, 1986). Clearly, over and beyond the general adherence to cultural and social norms, some individuals develop strong personal attitudes to weight and shape.
Expectations, such as perceived calorie intake, have been found to influence body size judgements (Crisp & Kallucy, 1974; Thompson, Coovert, Pasman & Robb, 1993) in both anorectic and non-anorectic young women. Moreover, at some point, the cognitions that eating disorder Ss have about their bodies appear systematic and stable. On the other hand, eating disorder Ss are particularly sensitive to the ‘instructional effect’, whereby they indicate they ‘feel fatter’ than they actually betieve themselves to be. (f) Individual psychopathology
Psychopathology clearly influences body image (e.g. anorexia and bulimia nervosa) and is itself almost certainly influenced by many of the other variables outlined above (e.g. cultural and social norms, individual attitudes to weight and shape, etc.).
Finally, we should not forget the possible role of biological factors in influencing personal body image, at least in terms of its day-to-day manifestation. For example, one study has reported a relationship between BID and stage of the menstrual cycle (Altabe & Thompson, 1990); while in a recent study (Robinson ef af., 1994) we found a significant correlation between basal metabolic
502
PETERDAVID SLADE
rate and BID. Our tentative conclusion from the latter is that bulimia leads to a lowering of metabolic rate which is experienced as ‘sluggishness’ and that the latter contributes to feelings of ‘fatness’, which is then expressed in BID. Clearly further research is needed in this area.
7. FINAL
CONCLUSION
Body image is best viewed as a ‘loose mental representation of the body’s shape, form and size’, which is influenced by a variety of historical, cultural and social, individual and biological factors, which operate over varying timespans. Researchers and clinicians need to appreciate this complexity when planning their studies and interventions.
REFERENCES Altabe, M. & Thompson, J. K. (1990). Menstrual cycle, body image and eating disturbance. International Journal of Eating Disorders, 9, 395402. Askevold. F. (1975)). Measuring body image-preliminary report of a new method. Psychotherapy and Psychosomatics, 26, 7 l-77. Bowden, P. K., Touyz, S. W., Rodriguez, P. J, Hensley, R. & Beumont, P. J. V. (1989). Distorting patient or distorting instrument? Body shape disturbance in patients with anorexia nervosa and bulimia. British Journal of Psychiatry, 15.5, 196201. Brindred, P. M. J., Bushnell, M. A., McKenzie, J. M. & Wells, J. E. (1990). Body image distortion revisited: temporal instability of body image distortion in anorexia nervosa. International Journal of Eating Disorders, 9, 695-701. Brodie, D. A. & Slade, P. D. (1988). The relationship between body image and body fat. Psychologicul Medicine, I8,623-631. Bruch, H. (1962). Perceptual and conceptual disturbances in anorexia nervosa. Psychosomatic Medicine, 24, 187-194. Cash, T. F. & Brown, T. A. (1987). Body image in anorexia nervosa and bulimia nervosa: a review of the literature. Behaviour ~od~cation, I I, 487452. Collins, J. K., Beumont, P. E., Touyz, S. W., Krass, J., Thompson, P. & Philips. T. (1987). Variability in body shape perception in anorexic, bulimic, obese and control subjects. International Jourmd of Eating Disorders, 6, 633-638. Crisp, A. H. (1985). Regulation of the self in adolescence with particular references to anorexia nervosa. Transactions of the Medical Society of London, IOO,67-74. Crisp, A. H. & Kallucy, R. S. (1974). Aspects of the perceptual disorder in anorexia nervosa. British Journal of Medical Psychology, 47, 349-361. Cumming, W. J. K. (.1988). The neurobiology of the body schema. British JournaI of Psychiatry, I53 (Suppi. Z), 7-I 1. Franzen, U., Florin, I., Schneider, S. LBMeier, M. (1988). Distorted body image in bulimic women. Journalof Psychosomatjc Research, 32, 445-450. Gardner, R. M. & Moncrieff, C. (1988). Body image distortion in anorexics as a non-sensory phenomenon: a signal detection approach. Journal of Clinical Psychology, 44, 101-107. Gardner, R. M. St Morrell, J. A. (1991). Body size judgements and eye movements of body regions in obese subjects, Perceptual and Motor Skills, 73, 675682. Garner, D. M., Garfinkel, P. E. & Olmsted, M. P. (1983). An overview of the socio-cultural factors in the development of anorexia nervosa. In Darby, P. L. er al. (Eds), Anorexia nervosa: recent d~eIopments (pp. 6.5-82). New York: Liss. Hamilton, K. & Wailer, G. (1993). Media influences on body size estimation in anorexia and bulimia: an experimental study. British Journal of Psychiatry, 162, 837-840. McCarthy, M. (1990). The thin ideal, depression and eating disorders in women. Behauiour Research and Therapy, 28,205216. Norris, D. L. (1984). The effects of mirror confrontation on self estimation of body dimensions in anorexia nervosa, bulimia and two control groups. Psychological Medicine, 14, 835-842. Proctor, L. & Morley, S. (1986). Demand characteristics in body size estimation in anorexia nervosa. British Journal of Psychiatry, 149, 113-I f8. Robinson, S., Brodie, D. A., Dewey, M. E. & Shde, P. D. (1994). Body image in bulimia nervosa: an inv~tigation of the effects of combined manipulations. In preparation. Schilder, P. (1935). The image and appearance of the human body; studies in the constructive energies of the psyche. London: Kegan Paul. Slade, P. D. (1988). Body image in anorexia nervosa. British Journal of Psychiatry, 153(Suppl. 2), 20-22. Slade, P. D. & Brodie, D. A. (1994). Bodv image distortion and eating disorder: a reconceutualisation based on the recent literature. European Eating DisordersWRevi&, in press. Sobal. J. & Stunkard, A. J. (1989). Socio-economic status and obesity: a review of the literature. Psychoiogical Bulletin, IOS, 260-275. Szmukler, G. I., Eisler, I., Gillies, C. & Hayward, M. E. (Eds) (1986). The implications of anorexia nervosa in a ballet school. Anorexia nervosa und bufimic disorders. Oxford: Pergamon Press. Thompson, J. K. (1990). Body image disturbance: assessment and treatment. New York: Pergamon Press. Thompson, J. K., Coovert, D. L., Pasman, L. N. & Robb, J. (1993). Body image and food consumntion: three laboratorv studies of perceived calorie content. International Journal‘of Eating Disordsrs, 14, 445458. . Wailer, G., Hamilton, K. & Shaw, 3. (1992). Media influences on body size estimation in eating disordered and comparison subjects. British Review of Bulimia and Anorexia Nervosa, 6, 8187. Whitaker. A., Davies, M., Shaffer. D.. Johnson. J.. Abrams, S.. Walsh. T. & Kahkow. K. (1989). The strueele to be thin: a survey of anorexic and bulimic symptoms in a non-referred adolescent population. ~~yc~o~o~~~a~ Medic& 19, l43-163. Whitehouse, A. M., Freeman, C. P. L. & Annandale, A. (1988). Body size estimation in anorexia nervosa. Bri/ish Journal of Psychiatry, 153 (Suppl. 2), 23-26.
Pergamon
0005-7967(94)EOOO9-8
Thu. Vol. 32, No. 5, pp. 497-502, 1994 ElsrvierScienceLtd Printedin Great Britain 0005-7967/94 $7.00 + 0.00
INVITED ESSAY WHAT
IS BODY PETER DAVID
IMAGE?
SLADE
Department of Clinical Psychology, School of Health Sciences, Faculty of Medicine, The Whelan Building, P.O. Box 147, Liverpool L69 3BX, England (Received 21 December
1.
1993)
INTRODUCTION
The concept of ‘body image’ was first formulated as an important and integral psychological phenomenon by the German writer, Schilder, in his monograph The Image and Appearance of the Human Body, which was published in English in 1935. In his monograph Schilder spoke of body image as “the picture of our own body which we form in our mind, that is to say the way in which the body appears to ourselves”. In recent times the definition has been expanded to refer to “the picture we have in our minds of the size, shape and form of our bodies; and to our feelings concerning these characteristics and our constituent body parts” (Slade, 1988). That is, body image is viewed as having two main components, a ‘perceptual component’ and an ‘attitudinal component’. These correspond to the distinction that is often drawn between ‘body percept’ and ‘body concept’. Paralleling this conceptual distinction, a similar one is made practically in the experimental literature on eating and weight disorders, between techniques which are focused on the assessment of: (1) the accuracy of an individual’s body size estimation; and (2) the attitudes/feelings an individual has towards their own body. The former is viewed as a ‘perceptual’ judgement, while the latter is generally considered to reflect ‘attitudinal, affective and cognitive’ variables. The recent literature on ‘body image’ has been greatly influenced by applied clinical concerns. These involve three main areas. The first, and the most influential area, is that of specific ‘neurological disorders’ in which patients exhibit a faulty perception of their own body. For example, neglect syndromes in which patients fail to recognize a hemiplegia or respond to a part of their body as though it did not exist [see the review by Cumming (1988)]. The second area is that of body image distortion (BID) as observed in patients with either an eating disorder (i.e. anorexia nervosa and bulimia nervosa) or a weight disorder (i.e. obesity). As this is the area where the most systematic experimental work has been done, I shall be focusing on this research later. The final clinical area relates to a highly specific problem concerning body image concern, which is viewed as involving a delusional misperception, and is referred to as ‘body dysmorphophobia’. In all these areas the ‘misperception’ of body size and shape is the central concern. One effect of this amalgamation of problems from differing areas (particularly from neurological disorders) is to reinforce the notion that body image is primarily a perceptual phenomenon. In this essay I shall argue that body image is not a simple perceptual phenomenon and that, even when we set out to measure an individual’s perception of their own body, the judgements the individual makes are highly influenced by cognitive, affective, attitudinal and other variables. 2. EARLY
OBSERVATIONS
ON
BODY
IMAGE
IN
THE
EATING
DISORDERS
The pioneering observations in this area were made by Hilde Bruch in the early sixties (e.g. Bruch, 1962). She was struck by the adamant attitude of emaciated anorectic patients that their bodies were actually ‘fat’ and came to the opinion that this was a central and diagnostic feature 497
PETERDAVID SLADE
498
of the psychopathology of anorexia nervosa. Moreover, Bruch argued that this distorted body image was a “disturbance of delusional proportions”, with the implication that it was fixed and resistant to direct attempts at modification. The influential nature of the latter view has meant that there have been very few attempts at body image therapy with eating disorder Ss and, indeed, to date there have still been no published controlled trials of such an intervention. By contrast, there have been numerous attempts to test the basic thesis of Bruch that eating disorder Ss possess a distorted body image [see recent reviews by Cash & Brown (1987), Thompson (1990) and Slade & Brodie (1994)]. In the latter we analysed all the studies which had measured body size estimation accuracy and came to the following conclusions: (a) that individuals suffering from an eating disorder, whether anorexia or bulimia nervosa, do tend to overestimate their physical size (bodily widths); (b) that randomly selected female controls, and psychiatric groups, also overestimate their physical size, albeit to a lesser extent; and that (c) the tendency to overestimate physical size is neither unique to individuals suffering from an eating disorder, nor is it diagnostic. In our review (Slade & Brodie, 1994) we outlined five sets of recent observations which have led us to reformulate our views on the nature of BID in individuals suffering from an eating disorder. I shall briefly review these observations and the conclusions they led us to adopt. I shall then describe two other sets of observations which seem to me to be important in formulating a wider theory of the nature of body image. 3. RECENT
OBSERVATIONS
ON
BODY
IMAGE
IN THE
EATING
DISORDERS
(a) ‘Attitudinal bias’ ZIS‘perceptual inaccuracy’
A classic study was reported by Gardner and Moncrieff (1988), in which they used a signal detection approach to separate perceptual from attitudinal bias. They found no difference between 9 anorectic and 9 female control Ss in terms of sensory sensitivity but a significant difference in terms of bias. They concluded, therefore, that the body image judgement difference between the groups was primarily attitudinal in nature.
Following the early lead given by Crisp and Kallucy (1974), a series of recent studies have examined the effects of verbal instruction on body image accuracy judgements (Proctor & Morley, 1986; Franzen, Florin, Schneider & Meier, 1988; Bowden Touyz, Rodriguez, Hensley & Beumont, 1989; Robinson, Brodie, Dewey & Slade, 1994). All four of these studies have used experimental procedures and have compared the body image estimates of eating disorder Ss and controls under two main instructional conditions-‘cognitive’ (make your judgements according to how you THINK you look) and ‘affective’ (make your judgements according to how you FEEL you look). There is a remarkable consistency in the pattern of results across the studies. In all four studies eating disorder Ss exhibited significantly greater overestimation of body size in response to the ‘affective’ instructions compared to the ‘cognitive’ instructions; the controls were not affected by the differential instruction. Thus, the ‘instructional effect’ appears to be specific to eating disorder Ss. Moreover, in our study we retested Ss 1 week later and obtained the same result. The specificity of the ‘instructional effect’ appears to be both robust and reliable. (c) Variability in accuracy judgements
Unlike most studies in the field which report their findings in terms of average scores, Collins, Beumont, Touyz, Krass, Thompson and Philips (1987) decided to analyse their data in terms of the number of S’s falling into one of three accuracy bands. The bands were: accurate (i.e. within 14% of actual size); underestimation (i.e. 15% or more below actual size); and overestimation (i.e. 15% or more above actual size). They analysed data collected from four groups. The first group was a normal group (n = 60), of whom 80% fell within the accurate range and can therefore be characterized as accurate estimators. A second group were buiimics (n = 24), of whom 50% fell in the accurate range and a further 42% fell in the overestimation range. Thus, bulimics are either accurate estimators or are biased towards viewing themselves as being ‘fat’. By contrast with these two groups, the other two groups of obese (n = 150) and anorectic (n = 78) Ss had sizeable
What
is
499
body image?
percentages in each of the three categories of underestimation, accurate estimation and overestimation. For the obese these were 16, 52 and 32% respectively; while for the anorectics the percentages were 23,41 and 36%. The obese and anorectics were therefore more variable than the other groups, which is interesting because they are more likely to have had histories of repeated weight change. Such a history, I would suggest, may have the effect of loosening their ‘body image’ and thereby rendering them more liable to both overestimation and underestimation of body size.
(d) Efects of ‘mirror confrontation’ on body size estimation A study by Norris (1984) reported the size estimation accuracy judgements of four groups of Ss before and after a period of self mirror gazing. Neither the normal control group nor the emotional control group were affected by the manipulation; while both the bulimic and the anorectic groups showed a reduction in size estimation following the period of mirror confrontation. The manipulation produced change only in eating disorder Ss. (e) Evidence that anorectics exhibit fluctuating body size judgements Although the observation has been made by many clinical researchers in the field, it was left to Brindred, Bushnell, McKenzie and Wells (1990) to draw attention to the temporal instability of body size judgements of individual anorectic patients. Using the video method, the authors present size estimation data on 7 anorectics tested weekly over a 4-week period, from which they conclude “Although no consistent change over time in BID (body image distortion) was evident for the group overall, all subjects except one showed significant variations, albeit in different directions. This change in individuals, obscured in the analysis of grouped data, suggests a lack of stability of BID over time”. 4. RECONCEPTUALISATION
OF BODY IMAGE EATING DISORDERS
DISTORTION
(BID)
IN THE
Hilde Bruch viewed BID as a fixed and implacable feature of anorectics, which is of delusional proportions and therefore is NOT amenable to direct intervention. On the basis of the recent observations described above we have come to a different conclusion: “that individuals with eating disorders do NOT have a fixed, implacable distorted body image in the manner implied in Bruch’s writings; rather, they have an UNCERTAIN, UNSTABLE and WEAK body image; such that, when confronted by enthusiastic researchers and clinicians, they err on the side of caution and overestimate their body size”.
What important factors then lead eating disorder Ss, on average, to overestimate their body dimensions on size estimation tasks? In our recent review (Slade & Brodie, 1994) we suggested that the most likely explanation for such a bias is to be found in socio-cultural theories such as that of Garner, Garfinkel and Olmsted (1983). Socio-cultural theories suggest that the Zeitgeist among females in Western societies is towards a ‘thin body cult’ [see the review by McCarthy (1990)] and away from a higher body weight and obesity [see the review by Sobal & Stunkard (1989)]. Furthermore, these theories suggest that this desire for thinness is reflected in, and reinforced by, the media. There is now direct evidence starting to appear to support this proposition (e.g. Hamilton & Waller, 1993; Waller, Hamilton & Shaw, 1992). The latter have demonstrated that individuals suffering from an eating disorder exhibit a significant increase in their body size overestimation following exposure to magazine pictures of thin female models, while female controls are unaffected by a manipulation of this kind. Thus, social and cultural norms may have a specific and powerful effect on those individuals who go on to develop an eating disorder. We therefore propose the following mechanism for such an hypothetical effect: “That the cultural ideal in developed societies conveys the message that females should women, particularly those with a WEAK body image, respond to this message by judging consequently exhibit a marked tendency towards overestimation of body size or BID”.
5. OTHER
RELEVANT
be thin: and that young themselves to be fat and
OBSERVATIONS
In order to set the latter conclusions with respect to BID and eating disorders in a wider context, two other sets of observations are of direct interest. First, is the common observation concerning
PETERDAVID SLADE
500
the magnitude of judgements made on ‘ascending’ and ‘descending’ trials. With the sole exception of the image marking procedure of Askevold (1975) in all experimental methods for assessing size estimation accuracy, Ss are required to make their judgements of body size on ascending trials (where the comparison starts as thin and then becomes progressively fatter) and on descending trials (where the comparison starts as fat and then becomes progressively thinner). The common finding is that Ss produce much lower judgements on ascending as opposed to descending trials (e.g. Whitehouse, Freeman & Annandale, 1988; Gardner & Morrell, 1991; Brodie & Slade, 1988). A possible inte~retation of this common observation is that the mental representation that we have of the outline of our bodies is a loose one; and that this representation involves a body image ‘band’ (outline) which varies in width according to the past experience of the individual, the influence of social and cultural norms and the influence of a variety of individual factors. Another interesting and possibly important observation was made by Gardner and Morrell (1991) who found that obese Ss were more accurate in making judgements about their back than they were in judging their front. This suggests the possibility that repeated experience of viewing the body from one perspective (i.e. the front), particularly when the individual’s body may have been liable to substantial weight and bodily change over time, may have a distorting influence on body perception judgements. That is, fluctuating external sensory input, in combination with fluctuating internal input, may lead to an uncertain and distorted mental representation of the body. Certain tentative conclusions can be drawn from the above sets of observations, namely: (a) People have a mental representation of their bodies which is not fixed but rather takes a finite range (a body image band). (b) Given no particular emotional or attitudinal bias, the average judgement will be in the middle of the range (i.e. an accurate one). (c) Given a strong concern about personal body size, individuals will veer towards the outer extremities of the finite range (body image band), thus demonstrating BID. For such individuals this represents their ‘worst case scenario’. I shall now outline a general model of body image, conceived as a ‘loose mental representation of the body’, and the factors which appear to affect its development and manifestation. 6. TOWARDS
A MODEL
OF BODY
IMAGE
This essay is concerned with identifying the nature of body image. A general schematic model is presented in Fig. 1. This suggests that body image may be conceived as a ‘loose mental representation of the body’ which is influenced by at least seven sets of factors. Each of these will now be described briefly. (a) History of sensory input to body experience
Throughout the life span the individual receives sensory input of a visual, tactile and kinaesthetic nature on the form, size, shape and appearance of his/her body. The input is not static but varies over time and is viewed as shaping up the general ‘mental representation of the body’. @) History of wseightchange~~uctuation
The individuals who appear to have the most variable body image are anorectics and the obese. These are people who are most likely to have experienced major fluctuations in weight, the effect of which can be construed as loosening body image and leading to a broader ‘finite range/band’. (c) Culturai and social norms The fact of cultural differences in the prevalence of eating disorders has been well-established, as has the sex or social difference (McCarthy, 1990). In addition, recent evidence has established that eating disorder Ss are more prone to influence by exposure to media images of thin body types compared with non-eating disorder controls (Hamilton & Waller, 1993: Waller et al., 1992). Clearly some cultures (particularly Western ones) encourage the ‘thin body cult’ goal, especially for young females. This undoubtedly then serves to sharpen up individual attitudes to ideal body size and shape in selected subgroups in those societies.
What is body image?
Cotturaf
and Social
‘LowsIp!mental representation
501
Indiuidual weight
attitudes ta and shape
Cognitiue and affectiue variables
Fig. 1. A model of the factors influencing the development and manifestation of body image.
Cd) ~ndividuul uttit~des to weight and shqe
Studies in both the U.S.A. (Whitaker, Davies, ShaiTer, Johnson, Abrams, Walsh & Kalikow, 1989) and in the U.K. (Crisp, 1985) have found that 60-70% of 17-year-old females admit to dieting during the previous year, compared with only 20% of same-aged boys. Similarly, Whitaker et al. (1989) found that 84% of I7-year-aid girls ‘desired to lose weight’ compared with only 40% of boys of the same age. Thus, girls in Western societies are much more concerned than boys with conforming to the ‘thin body’ prescription: and this is especially so for certain subgroups, such as ballet dancers (Szmukler, Eisler, Gillies & Hayward, 1986). Clearly, over and beyond the general adherence to cultural and social norms, some individuals develop strong personal attitudes to weight and shape.
Expectations, such as perceived calorie intake, have been found to influence body size judgements (Crisp & Kallucy, 1974; Thompson, Coovert, Pasman & Robb, 1993) in both anorectic and non-anorectic young women. Moreover, at some point, the cognitions that eating disorder Ss have about their bodies appear systematic and stable. On the other hand, eating disorder Ss are particularly sensitive to the ‘instructional effect’, whereby they indicate they ‘feel fatter’ than they actually betieve themselves to be. (f) Individual psychopathology
Psychopathology clearly influences body image (e.g. anorexia and bulimia nervosa) and is itself almost certainly influenced by many of the other variables outlined above (e.g. cultural and social norms, individual attitudes to weight and shape, etc.).
Finally, we should not forget the possible role of biological factors in influencing personal body image, at least in terms of its day-to-day manifestation. For example, one study has reported a relationship between BID and stage of the menstrual cycle (Altabe & Thompson, 1990); while in a recent study (Robinson ef af., 1994) we found a significant correlation between basal metabolic
502
PETERDAVID SLADE
rate and BID. Our tentative conclusion from the latter is that bulimia leads to a lowering of metabolic rate which is experienced as ‘sluggishness’ and that the latter contributes to feelings of ‘fatness’, which is then expressed in BID. Clearly further research is needed in this area.
7. FINAL
CONCLUSION
Body image is best viewed as a ‘loose mental representation of the body’s shape, form and size’, which is influenced by a variety of historical, cultural and social, individual and biological factors, which operate over varying timespans. Researchers and clinicians need to appreciate this complexity when planning their studies and interventions.
REFERENCES Altabe, M. & Thompson, J. K. (1990). Menstrual cycle, body image and eating disturbance. International Journal of Eating Disorders, 9, 395402. Askevold. F. (1975)). Measuring body image-preliminary report of a new method. Psychotherapy and Psychosomatics, 26, 7 l-77. Bowden, P. K., Touyz, S. W., Rodriguez, P. J, Hensley, R. & Beumont, P. J. V. (1989). Distorting patient or distorting instrument? Body shape disturbance in patients with anorexia nervosa and bulimia. British Journal of Psychiatry, 15.5, 196201. Brindred, P. M. J., Bushnell, M. A., McKenzie, J. M. & Wells, J. E. (1990). Body image distortion revisited: temporal instability of body image distortion in anorexia nervosa. International Journal of Eating Disorders, 9, 695-701. Brodie, D. A. & Slade, P. D. (1988). The relationship between body image and body fat. Psychologicul Medicine, I8,623-631. Bruch, H. (1962). Perceptual and conceptual disturbances in anorexia nervosa. Psychosomatic Medicine, 24, 187-194. Cash, T. F. & Brown, T. A. (1987). Body image in anorexia nervosa and bulimia nervosa: a review of the literature. Behaviour ~od~cation, I I, 487452. Collins, J. K., Beumont, P. E., Touyz, S. W., Krass, J., Thompson, P. & Philips. T. (1987). Variability in body shape perception in anorexic, bulimic, obese and control subjects. International Jourmd of Eating Disorders, 6, 633-638. Crisp, A. H. (1985). Regulation of the self in adolescence with particular references to anorexia nervosa. Transactions of the Medical Society of London, IOO,67-74. Crisp, A. H. & Kallucy, R. S. (1974). Aspects of the perceptual disorder in anorexia nervosa. British Journal of Medical Psychology, 47, 349-361. Cumming, W. J. K. (.1988). The neurobiology of the body schema. British JournaI of Psychiatry, I53 (Suppi. Z), 7-I 1. Franzen, U., Florin, I., Schneider, S. LBMeier, M. (1988). Distorted body image in bulimic women. Journalof Psychosomatjc Research, 32, 445-450. Gardner, R. M. & Moncrieff, C. (1988). Body image distortion in anorexics as a non-sensory phenomenon: a signal detection approach. Journal of Clinical Psychology, 44, 101-107. Gardner, R. M. St Morrell, J. A. (1991). Body size judgements and eye movements of body regions in obese subjects, Perceptual and Motor Skills, 73, 675682. Garner, D. M., Garfinkel, P. E. & Olmsted, M. P. (1983). An overview of the socio-cultural factors in the development of anorexia nervosa. In Darby, P. L. er al. (Eds), Anorexia nervosa: recent d~eIopments (pp. 6.5-82). New York: Liss. Hamilton, K. & Wailer, G. (1993). Media influences on body size estimation in anorexia and bulimia: an experimental study. British Journal of Psychiatry, 162, 837-840. McCarthy, M. (1990). The thin ideal, depression and eating disorders in women. Behauiour Research and Therapy, 28,205216. Norris, D. L. (1984). The effects of mirror confrontation on self estimation of body dimensions in anorexia nervosa, bulimia and two control groups. Psychological Medicine, 14, 835-842. Proctor, L. & Morley, S. (1986). Demand characteristics in body size estimation in anorexia nervosa. British Journal of Psychiatry, 149, 113-I f8. Robinson, S., Brodie, D. A., Dewey, M. E. & Shde, P. D. (1994). Body image in bulimia nervosa: an inv~tigation of the effects of combined manipulations. In preparation. Schilder, P. (1935). The image and appearance of the human body; studies in the constructive energies of the psyche. London: Kegan Paul. Slade, P. D. (1988). Body image in anorexia nervosa. British Journal of Psychiatry, 153(Suppl. 2), 20-22. Slade, P. D. & Brodie, D. A. (1994). Bodv image distortion and eating disorder: a reconceutualisation based on the recent literature. European Eating DisordersWRevi&, in press. Sobal. J. & Stunkard, A. J. (1989). Socio-economic status and obesity: a review of the literature. Psychoiogical Bulletin, IOS, 260-275. Szmukler, G. I., Eisler, I., Gillies, C. & Hayward, M. E. (Eds) (1986). The implications of anorexia nervosa in a ballet school. Anorexia nervosa und bufimic disorders. Oxford: Pergamon Press. Thompson, J. K. (1990). Body image disturbance: assessment and treatment. New York: Pergamon Press. Thompson, J. K., Coovert, D. L., Pasman, L. N. & Robb, J. (1993). Body image and food consumntion: three laboratorv studies of perceived calorie content. International Journal‘of Eating Disordsrs, 14, 445458. . Wailer, G., Hamilton, K. & Shaw, 3. (1992). Media influences on body size estimation in eating disordered and comparison subjects. British Review of Bulimia and Anorexia Nervosa, 6, 8187. Whitaker. A., Davies, M., Shaffer. D.. Johnson. J.. Abrams, S.. Walsh. T. & Kahkow. K. (1989). The strueele to be thin: a survey of anorexic and bulimic symptoms in a non-referred adolescent population. ~~yc~o~o~~~a~ Medic& 19, l43-163. Whitehouse, A. M., Freeman, C. P. L. & Annandale, A. (1988). Body size estimation in anorexia nervosa. Bri/ish Journal of Psychiatry, 153 (Suppl. 2), 23-26.