Severe body image concerns under-recognized in teens

Adolescents with negative body image concerns are more likely to be depressed, anxious, and suicidal than those without intense dissatisfaction over their appearance, even when compared to adolescents with other psychiatric illnesses, according to a new study by researchers at Bradley Hospital, Butler Hospital and Brown Medical School.

Researchers assessed the prevalence and clinical correlates of body image concerns including: body dysmorphic disorder (BDD), eating disorders (ED) (such as bulimia or anorexia), and other clinically significant concerns over shape/weight in adolescent inpatients at Bradley Hospital, the nation's first psychiatric hospital for children and adolescents. Classic BDD is a preoccupation with an imagined physical defect in appearance or a vastly exaggerated concern about a minimal defect, like a crooked nose or imperfect complexion. Weight-related BDD, however, is classified as distressing and impairing preoccupations with one's weight and shape - ie: thinking one's thighs are too fat or one's waist is too big.

The study found that one third of inpatient adolescents had problematic body image concerns, and that these patients were more severely ill than other adolescent inpatients in a number of important domains. Specifically, those with BDD and shape/weight preoccupations had significantly higher levels of depression, anxiety, and suicidality than other patients with no body image concerns. Those with eating disorders had significantly higher rates of depression than those without body image concerns.

"These findings underscore just how central feelings about one's appearance tend to be in the world of teenagers and how impairing these concerns can be," says lead author, Jennifer Dyl, PhD, with Bradley Hospital and Brown Medical School.

This is the first study to show that adolescents with BDD and with shape/weight preoccupations display higher levels of symptoms in areas like depression, anxiety and suicidality, as compared to other adolescents presenting with psychiatric disorders such as behavioral, psychotic, or mood and anxiety disorders who do not have body image concerns.

"This is important because distressing and impairing body image concerns appear to be very prevalent among adolescents with psychiatric illnesses, and are related to a higher degree of distress and impairment," says author Jennifer Kittler, PhD with Bradley Hospital and Brown Medical School.

An additional finding revealed that in addition to higher levels of depression, anxiety and suicidality, patients with shape/weight preoccupations expressed higher levels of dissociation (a coping style characterized by blocking out emotions), sexual preoccupation/distress, and post-traumatic stress disorder (PTSD), suggesting that such concerns may be related to the experience of past physical or sexual abuse.

Interestingly, the authors found that the majority of the adolescents in the study were not actually overweight.

Two hundred and eight consecutively admitted patients (ages 12 to 17) on the adolescent inpatient unit of Bradley Hospital completed the Body Dyspmorphic Disorder Questionnaire (BDDQ) as part of their admission evaluation. The questionnaire assesses the presence of BDD by asking whether respondents are very worried about how they look, think about their appearance problems a lot, and wish they could think about them less, and whether their main appearance concern is that they are not thin enough, or might become too fat. It also asks for the amount of time that they spend focusing on appearance concerns.

"We found that 6.7 percent of patients on the adolescent inpatient unit at Bradley Hospital met criteria for classic (non-weight-related) BDD, but that a much higher percentage (22.1 percent) exhibited distressing and impairing concerns with their weight and shape," says Kittler.

The study will be published in the June 2006 issue of the journal of Child Psychiatry and Human Development.

Body image concerns under-recognized in teens

These findings are especially concerning for treatment providers and parents, the authors say, because the majority of adolescents in this study were not receiving psychiatric treatment specifically targeted towards their body image problems. They were most commonly being treated for mood disorders, anxiety disorders, and posttraumatic stress disorder and these body image preoccupations may well have been contributing to the events leading to their hospitalization.

"We have indeed seen a number of teens entering the hospital whose negative feelings about their appearance is a major influence on suicidal thoughts and even suicide attempts, a fact which is often initially not recognized by parents and even professionals," says Dyl.

The authors looked at whether individuals determined to have BDD via a self-report measure were diagnosed with BDD by their clinician. They found that only 1 of 14 participants with definite or probable BDD was diagnosed with BDD in the clinical record.

"This is likely due to clinicians' lack of systematic questioning about BDD, as well as patients' embarrassment and reluctance to reveal their symptoms, which may be particularly characteristic of adolescents," they write.

The authors conclude that severe body image disturbances among adolescents are likely to be under-recognized and under-treated, and may be related to other forms of psychological distress (including depression and suicidality). They also note that since many adults presenting in psychiatric settings often report that preoccupation with their appearance first began in adolescence, it is all the more important to recognize and begin to treat body dysmorphic disorder and other body image concerns in the teenage years, to prevent the problem from becoming a more chronic condition.

Even in the absence of an eating disorder, the study finds that body image concerns can be impairing, preoccupying and distressing for teens, taking up a great deal of mental energy and detracting from their quality of life

"Helping teens verbalize their negative feelings and concerns about their appearance is the first step in getting them to value themselves as individuals and recognize the importance of other non-weight, or non-appearance-based qualities and activities as contributors to their self-esteem and self-worth," Dyl explains.