Perhaps Thornton Wilder’s Our Town, Act I, set in 1901, simply depicts a natural tendency for teens concerned about their looks to seek reassurance from parents, to compare themselves to others, to be too rushed to eat and to hope for acceptance from peers.

But problems arise when natural tendency turns to obsession, says Joel Kevin Thompson, PhD, Professor of Psychology at the University of South Florida. The term “normative discontent” has often described our society’s interest in appearance, and it means that, “essentially, it is quite normal to be concerned with looks. Helping teens who cross the line between normalcy and obsession is handled best by a professional specializing in body image and eating disorders,” he says. Thompson explains that when normative discontent becomes excessive it is a precursor to eating disorders.

Indeed, 86 years after Our Town, body dysmorphic disorder (BBD) first entered the diagnostic nomenclature of the Diagnostic and Statistical Manual of Mental Disorders, third edition, Revised (DSM-III-R). A “preoccupation with some imagined defect in appearance.” If a slight physical anomaly is present, the person’s concern is markedly excessive. The preoccupation causes clinically significant distress or impairment in social, occupational or other important areas of functioning. Because Emily does not seem to dwell on any perceived imperfection and accepts compliments from George and her father, though, it would seem that her questions are commonplace and natural.

Today, however, mental healthcare practitioners pay scrutiny to adolescents and teens who are preoccupied with an imagined flaw. Affective spectrum-disorders included among obsessive-compulsive spectrum disorders are body-dysmorphic disorder (classically called dysmorphophobia) and anorexia nervosa.

Recognizing BDD

Teens with body dysmorphic disorder are most often preoccupied with a perceived abnormality of the nose, hair or complexion; but the preoccupation can focus on any body part or on the shape and weight of the body. Often secrecy delays diagnosis and prompt treatment.

BDD sufferers feel trivialized and misunderstood and cannot believe that others do not see their perceived ugliness. They may touch their imperfection frequently. They may groom excessively. They may pick at their skin. They may measure their imagined unattractive body part. They may read inordinately about their perceived problem. They often may check their appearance in mirrors, camouflage or cover their imagined blemish with makeup or a hat or clothing.

On the contrary, they may avoid mirrors. As their obsession increases, anxiety or depression shackles the teens. They may find it difficult to concentrate. They may leave school and quit jobs. They may withdraw from social interactions. As their cases intensify, they can become controlled by their perceived flaw and become incapacitated.

Katharine A. Phillips, MD, author of The Broken Mirror, estimates that in the United States alone there may be more than five million people — from “all socioeconomic strata and from all walks of life” — who suffer from BDD. She says that BDD also has been reported in Europe, South America and Asia for a century, yet until recently it was neglected largely in the medical literature. Phillips feels that neurobiology lays the groundwork for BDD, and because BDD may respond to serotonin-reuptake inhibitors (SRIs), that suggests that disturbed brain chemistry plays a significant role along with psychological, sociocultural, genetic and environmental components.

Overcoming BDD

Karen, an attractive 17 year old, is one individual who obsessed about her perceived “large” nose, “small” breasts and “ugly” hair since age 13.

“They’re so horrible I get suicidal,” said Karen. “It’s why I overdosed. I couldn’t stand the pain anymore.” Karen thought about her looks every second of every day. She checked her reflection several hours a day, compared herself with others, and asked her mother “a million times a day” for reassurance that she looked OK.

Alan, a fine-looking 16 year old, became obsessed with acne, crow’s feet, and his ears that “stuck-out,” yet these qualities were not discernible to others. He frequently checked his appearance in mirrors, sought reassurance from his mother about his looks, covered his “defects” with makeup, and changed his hairstyle. He withdrew from his friends, could not bear to attend school and became housebound.

Both Karen and Alan improved with fluoxetine and again enjoyed life. Alan’s treatment also included cognitive behavior therapy (CBT) using cognitive rehearsal, imagery, identification of cognitive distortions and graded exposure.

Phillips says an SRI alone may be effective or a special combination of medications or a switch to a different SRI. SRIs and CBT are companion “core treatments” she finds useful. Karen and Alan were among four BDD cases that Katharine A. Phillips, MD, Katherine D. Atala, MD, and Ralph S. Albertini, MD, of Butler Hospital in Providence, Rhode Island, reported in the Journal of the American Academy of Child and Adolescent Psychiatry in 1995.

Recognizing eating disorders

When a teen’s concern centers around being thin, the condition often manifests itself as an eating disorder such as anorexia nervosa or bulimia nervosa. With anorexia or bulimia, teens often not only have a misperception regarding their shape and weight — seeing themselves as fat even though they are thin — but they also are held captive by a need for control. With both disorders, this control often centers on food intake and body shape and weight.

Paying attention to messages

Think back to Mrs. Webb’s words to Emily, “Eat your breakfast.” Do teens perceive such words as innocent encouragement or a controlling order? The Anorexia and Bulimia Nervosa Foundation of Victoria Inc. (ABNFV) in Glen Iris, Australia, reports that “there are many factors affecting the development of [eating] disorders — biological, psychological and sociological — so the relationship between parent and child need not be seen as the dominant cause. However, the reluctance to mature physically and emotionally, and issues of personal control between child and parent, could contribute to some cases of anorexia.” In 1988, Baylor College of Medicine in Waco, Texas, reported in “Kids and Food: Starting a Lifetime of Healthy Eating” that “parents are the greatest single influence on their children’s attitudes toward food and their food habits.”

Considering the family unit

Kay Bolter, PhD, a clinical psychologist with a full-time private practice in Redwood City, California, explains that the teens as well as their families must be informed that a unique and intricate combination of biochemical, psychological, societal and environmental factors set ED in motion for each individual. She explains that the teens must be led gently into exploring and understanding how their condition is a coping mechanism to help deal with their particular stresses. She adds, “Involving the family is essential for the success of the treatment, especially because the emotions the teens once were able to keep closely in check with the eating disorder will erupt once they begin to normalize their eating, and the restriction and/or bulimia starts to decrease.” Individual and family therapy can improve family dynamics and can help to create a positive prognosis for ED patients.

Recognizing the need for prevention

Don Williamson, Director of the Psychological Services Center at Louisiana State University and author of Assessment of Eating Disorders, is currently conducting a study on the prevention of eating disorders with the participation of local Girl Scout troops. In another study, his goal is to determine when children begin developing obsessions with body size and shape and when those obsessions change the individuals’ thinking processes about eating, dieting and body image. In the absence of prevention, early intervention is the next best effort. Williamson says that the recovery rate for an ED patient when treatment is begun in the first year of the disorder is 80 percent; but if treatment is delayed up to 10 years, the recovery rate is only 50 percent.

Contributing causes of eating disorders

During his treatment of over 2,000 patients with eating disorders, Williamson hypothesizes that the disorders arise from the complex interaction of a variety of social and psychological risk factors that are exacerbated by low self-esteem. These may include worry, family disturbance and sometimes even participation in certain sports that dictate an ideal body size. He maintains that in patients whom he has observed, eating disorders almost always have developed as a companion to an obsession with body size and shape. Williamson says that while ED arises from a multitude of paths, crossing the fine line from normative discontent and becoming chained to obsession is the final common pathway for developing eating disorders. He notes that while thousands of teens are bombarded by flashy advertising campaigns from the world of sports and fashion and by movies and other media, only small numbers are affected. He believes that to be affected, the teen must have the predisposition for obsessive thinking.

William N. Davis, PhD, is Vice President for Research and Program Development at The Renfrew Center of Philadelphia, and the Administrative Director of The Renfrew Center of New York City. “There clearly is a link between eating disorders and what the media and the fashion industry have done and continue to do,” says Davis. “Fifth and sixth graders,” he says, “are concerned with how their bodies look or will look and when asked to discuss their feelings, they point to the media.”

Sacker says, “People buy the images of ultra-thin super models, many of whom have been treated for eating disorders.” He quotes from a study in the Journal of International Eating Disorders; “Female fashion models do more than stir envy among women. Their images can actually lead to anger and depressed mood oftentimes underlying eating disorders.”
In rebuttal to advertisers and fashion controllers, the nonprofit organization based in Seattle, Eating Disorders Awareness and Prevention, Inc., encourages companies to advertise sensitively to help prevent the spread of ED.

Some companies that have responded favorably to their suggestions include Avia, Nicole Shoes, The Milk Board and the Jarlsberg Cheese Company. Avia even has invited EDAP to help plan future advertising campaigns.

EDAP has commended Nike, Champion Sportswear and Kellogg for their messages that focus on inner strength of individuals rather than on superficial appearance and size.

Sacker has said, “If only the media, designers and healthcare professionals could come together to provide a more realistic image for young people to emulate, what a healthier world we would have.”

The rising incidence of ED

Davis says, “Too much of an increase in the incidence of eating disorders over the past 30 years that appear directly related to changes in the fashion and advertising industries is too great to be accounted for by some genetic factor.”

As more attention is turned to these disorders, more cases will be uncovered whether a genetic marker is discovered, or not. Sacker, founder of HEED, Helping to End Eating Disorders, predicts that a genetic coding will be discovered that involves a neurotransmitter such as serotonin, for example, which plays a major role in depression, mood disturbances, OCD and disordered eating behaviors.

Sacker, co-author of Dying to Be Thin: A Guide to Anorexia Nervosa and Bulimia, believes that BDD and disordered eating behaviors are borne out of multiple existing biochemical, psychological, interpersonal and social factors. He also adds that feelings of inadequacy and lack of control, low self-esteem, loneliness, depression, anxiety and troubled familial relationships play a role as well as our society’s current preoccupation with the “perfect” and non-aging body.

He says that patients with BDD and ED often may seek — but are not helped by cosmetic surgery, modern dermatology and dental treatments, for they continue to see themselves just as they had before.

Sacker wonders if these disorders were present in larger numbers 20 or 30 years ago but were misdiagnosed. He is seeing “second generation anorexia in parents who were not treated but who walked a tightrope course of disordered eating behaviors very close to anorexia. Although they have given their children proper verbal feedback, the child observes and inculcates the behavior of the parent — the mother.” He treats even five and six year olds now who have anorexia and bulimia, yet he never would have imagined these disorders in individuals so young.

This multi-faceted problem does not stop here. He says that over the past five years the ratio of female to male patients with anorexia has changed from 20 females to one male to 12 females to one male. His data reflects an upsurge of affected males. Sacker believes that while the media and the fashion industry are pressuring men to crave taut, muscular bodies and are driving some males into disordered eating and some others into using steroids, other teens distressed by the impossibility of achieving a perfect body are going in still a different direction.
Both Sacker and Jack D. Osman, Co-director, with wife, Beverly, of The Wellness Farm, in Stewartstown, Pennsylvania, note that many male teens are heading for obesity not for the gymnasium or the YMCA to work out. According to them, “Teens are not getting ‘ripped’. Men in mid-life crisis are the ones pumping iron.”

Methods for healing

Cognitive therapy, cognitive-behavioral therapy, exposure and response prevention, and pharmaceutical intervention such as SRIs — clomipramine, fluoxetine, fluvoxamine, paroxetine, sertraline — and SRIs with busiprone added are among the most common treatments to try to deal with and control BDD. Systematic desensitization, which is similar to exposure, is used less. Nutritional therapy, cognitive-behavioral therapy, interpersonal and family therapy are being used with some success to treat ED.

Preventing BDD and ED

Thompson of South Florida, lead author of Exacting Beauty: Theory, Assessment and Treatment of Body Image Disturbance, says that a good strategy is to teach the acceptance of diversity of body shapes and sizes. “Cultural icons are the exception in terms of body size,” says Thompson, “for it is impossible for almost all adults, much less boys and girls to reach the level of muscularity or thinness of these individuals who are held up as the super models.” He explains that a problem is usually that people choose media archetypes as “comparison targets,” but if comparison is done, it would be healthier to consider a broad range of peers. He says that already there are reports of boys who avoid gym class because bigger boys will tease them about their lack of a muscular physique. He also says that surveys reveal steroid use is on an increase among boys and girls. He says that sports stars who use steroids are terrible models for youngsters.

Sacker, of HEED, says parents, are teachers and models by example. Parents, he says cannot teach their children something that they say unless they themselves practice it. Parents hold a key to prevention. Perhaps, societally, parents can make a difference where BDD and ED are concerned, for they can be mindful of values and messages that they convey regarding beauty, fitness, body shape, self-acceptance and foods. They can show healthful moderation and avoid categorizing foods as good or bad. They can model self-discipline not deprivation. They can enjoy exercise for fun and recreation, flexibility and cardiovascular fitness, rather than weight control.

William N. Davis, PhD, director of research activities at all Renfrew sites, oversees and revises all clinical outpatient programming and services based upon research findings. He cites the following cas as an example of how parental attitude can play a role in the creation of eating disorders. “Amy,” a patient, now over age 20, dates her eating disorder to her teens. Her mother, she says, was enormously affected by the fashion industry and the need to be thin. Amy, at age eight, was first told by her mother that she was too fat and that she should pay attention to her diet and her weight.

Her mother encouraged Amy to swim, to “elongate” Amy’s body so that she would be slimmer as she grew. As Amy reached early adolescence, her mother inundated her with “should looks” from the print media. Amy suffered from anorexia, which she conquered, but now she is symptomatically bulimic. Amy still sees herself as fat and Disproportionate, despite being well proportioned. Davis says, “Amy’s eating disorder is connected directly to her mom and to her mom’s ‘education’ of her when she was an adolescent.”

Davis’ treatment plan for Amy includes discussions of how women have been depicted in art over time and the use of air brushing to “perfect” images in photos in magazines. He encourages Amy to get comments from the caring people in her life so that she can be reassured of how she appears to others.

Davis says that people with eating disorders worry that if they relax their control over their symptoms, they will have to deal with other issues that they have pushed aside. Thus, he emphasizes the importance of replacing ED patients’ symptoms by helping them to risk new positive behaviors that they can control proactively. Proactive control, he says, is the most important key to treatment.

Parents or relatives or guardians can help protect adolescents and teens from skewed communications. Instead of babysitting youngsters with hundreds of TV channels, they can watch programs and advertisements with them to establish a personal rating system and to build a fortification against unhealthful messages. They also can approach companies with their concerns just as EDAP does.

Counselors hold keys in prevention and in treatment, for they can help to educate society and lead their patients toward healing.
Enlightening society and nurturing respect for acceptance of diversity can contribute to helping teens to see themselves in a gleaming mirror of self-acceptance.

Looking back on her 16th birthday, Emily Webb said, “Oh, earth, you’re too wonderful for anybody to realize you. Do any human beings ever realize life while they live it?”

With love and respect from family and friends and guidance from qualified professionals, teens can feel nurtured and appreciated; and they can realize and enjoy life while they live it.

Linda Davis Kyle is an internationally published health and fitness writer and a black belt in Shito-Ryu.

One person has commented on this article.

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Britney Kaye Jefferson Howard, Unregistered

i think that this is a very emotional article

 Posted 2008-02-07 14:06:57

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