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BODY-IMAGE IN ADOLESCENTS: A PSYCHIATRIC CONCEPT FOR THE PEDIATRICIAN

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BODY-IMAGE

IN ADOLESCENTS:

A

PSYCHIATRIC

CONCEPT

FOR

THE

PEDIATRICIAN

William A. Schonfeld, M.D.

Department of Psychiatry, Children’s Service, College of Physicians and Surgeons, Columbia University

(Submitted July 27, 1962; accepted for publication January 27, 1963.)

Presented at the X International Congress of Pediatrics, Lisbon, Portugal, September, 1962.

ADDRESS: 62 WaIler Avenue, White Plains, New York.

845

PEDIATRICS, May 1963

T

HE PEDIAThICIAN is assured by

psychi-atric colleagues and specialists working

with adolescentsl 2 that many of the

emo-tional problems of tile adolescent lie within

his province, yet he is apt to be

over-whelmed by psychiatric jargon. Tile

con-cept of body-image in adolescents,

how-ever, is vell within the pediatrician’s scope

and can be a very effective tool in guiding

him to a fuller understanding of adolescent

behavior.

This concept has been variously described

in the literature as self-awareness,

self-concept, body-ego, and body-schemata with

slightly different but overlapping

connota-tions. The idea of body-image as presently

utilized in psychiatry was developed largely

by Schilder in his efforts to integrate

bio-logical and psychoanalytical thinking and

recently further elaborated by Kolb.4

Schilder defined it as “tile image of our

body which we form in our mind-the way

in which our body appears to ourselves.”

Each of us carries around a mental image

of our own appearance which is more than

a mirror image and may or may not closely

approximate our actual body 5 In

fact, tile body-image, although wholly a

psychological phenomenon , embraces not

only our view of ourselves psychologically

1)tlt also physiologically and sociologicaliy.e

The adolescent’s intensified awareness of

ilis body stems partly from the

conscious-ness of his own physical development,

partly from the inflated emphasis assigned

to physical traits by schoolmates, and partly

from increasing identification with

cultur-ally determined standards.

In this study of body-image in

adoles-cence, three groups of cases were involved.

First were those seen in the endocrine,

adolescent, plastic surgery, and pediatric

clinics0 with actual inappropriate sexual

development-boys with enlarged breasts

ranging from pubertal hyperplasia to

pen-dulous gynecomastia; obese boys with

ap-parent feminization due to fat distribution;

boys and girls with puberty delayed beyond

16 years of age; boys and girls with short

stature, ranging from dwarfism to short

normals; girls with unusually small breasts,

breast hypertrophy or hirsutism. Some of

these adolescents evidenced overt

disturb-ance of behavior adaptation, but others

did not until further probed. Levy’s method

of integrating the physical and psychiatric

examinations to be discussed was useful in

tilis group since it enabled the examiner to

take advantage of the rapport and intimacy

established in the physical examination to

usher in the psychiatric interview.8

The second group of adolescents had no

physical abnormalities but still were overtly

concerned over their sexual adequacy. These

adolescents evidenced disturbances of

body-image through emotional problems ranging

from transient difficulties of adjustment,

conduct disorders, learning problems,

anx-ieties, and psychosomatic symptoms, to

psychoneurotic and schizophrenic reactions.

Others repressed their concern and

ex-pressed anxiety over their body-image only

after prolonged psychotherapy.

The third group of adolescents were those

using a physical defect as a rationalization

0 Columbia-Presbyterian Medical Center and

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846

of a more basic personality defect or social

ineptness.

The complicated constellation of

psycho-logical components that determine the

“structure” of the body-image, on both the

conscious and unconscious levels, may be

classified as follows: (1) the actual

sub/ec-tive perception of the body, both as to

ap-pearance and ability to function; (2) the

internalized psychological factors arising

out of the individual’s personal and

emo-tional experiences as well as distortions of

the body concept expressed as somatic

de-lusions; (3) the sociological factors, namely,

how parents and society react to the

in-dividual and the adolescent’s interpretation

of their reactions; and (4) the ideal

body-image, formulated by the individual’s

atti-tudes toward the body derived from his

experiences, perceptions, comparisons, and

identifications with the bodies of other

persons.

Modifications in the actual appearance

of the body may cause drastic changes in

the body-image through any of these

chan-nels. However, disturbances in body-image

result not only from disturbances of

body-percept but also from disturbances of

body-concept.6 The individual does not see his

body as it actually exists either because of

an inner emotional condition that

exagger-ates aberrations of development or as a

result of actual somatic delusions.

ORGANIZATION

OF THE BODY-IMAGE

Subjective Perception

The organization of body-image probably

begins intrauterine with the fetus exposed

to proprioceptive sensory impressions from

the vestibular apparatus and the receptors

in the muscles and joints. Then, after birth,

the mouth is the first area to be stimulated

by sucking and feeding, and from about

3 months on, the hand-to-mouth

relation-ship gets under way. The child begins to

use both hands and arms to grasp and

knead the mother’s breast and face, and to

explore his own body surface and contact

others. At the same time he finds that the

hand can substitute for tile nipple as a

pleasure device and can thereby relieve

tension. It is on these exploratory

move-ments of the infant’s hands that are founded

the beginnings of body-image, and the

body-ego. Subsequently, the child’s visual

discovery of the physical difference

he-tween the sexes has profound and

far-reach-ing implications in his psychologic

develop-ment.

Ordinarily, during childhood and

pre-adolescence, the body-image changes slowly.

Gradual alterations in appearance and

height are easily absorbed in the prevailing

picture the child has of his own body. Then,

with the upheaval of adolescence, the

tempo of change is greatly accelerated.#{176} IC)

Curran and Frosch called attention to tile

need for radical reconstructing of the

body-image during normal adolescence because

of the rapid changes taking place with

pubescence in size, body proportions, and

primary and secondary sexual

character-istics.

The growth process tends to be

asym-metrical. Physical changes do not always

take a sexually appropriate course, and any

delay in the onset of puberty is regarded

by the immature boy as evidence of

im-paired virility. The presence of this

dis-cordance in growth often tends to intensify

the usual instability found in adolescence,

further stimulating anxiety,

selfconscious-ness, and feelings of inadequacy.12

Incongruous secondary sexual

develop-ment, as in boys with gynecomastia, usually

ilas a deleterious effect. Tile more obvious

the defect is, the more likely that the

per-sonality adaptations are distorted.13 14

CASE 25: T. came alone to the clinic at

16 years of age for an “examination”

he-cause he had a “cough”. When examined it

was noted that both his breasts were

ap-preciably enlarged When asked to evaluate

his body, he admitted having been

con-cerned about his masculinity; however, he

was not ready to face directly the disturbed

body-image created by the gynecornastia

so that he had to rationalize his clinic visit.

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con-cern that he “would turn into a woman”,

and was repeatedly examining himself to

see if it were progressive. He withdrew

from all activities which would possibly

lead to physical exposure. His academic

work gradually declined due to his

preoc-cupation with fantasies involving his “sexual

conversion”. At the same time he was

get-ting into disciplinary difficulties at school

through clowning and defiance of

regula-tions. He had equated defiance with virility

and was determined to “prove” himself to

1)e a “man”.

Treatment consisted of supportive

psy-chotherapy followed by low calorie diet,

increased exercise, and bilateral

mastec-tomy.

REMARKS : Greenacre reaffirmed Schilder’s

contributions regarding the importance of

body-image as a factor in the picture one

has of one’s own identity.15 In the male, the

paramount features are ileight, the concept

of strength and muscular development, as

well as the length of the penis, presence of

testes, and hirsutism. Menarche, size of the

breasts, and hip development are typical

of tile female identity.

Stolz and Stolzmc found that 7.5% of a

group of 93 normal adolescent boys

ap-peared to be disturbed by their shortness

and 13% of 83 adolescent girls showed signs

of worry over their tallness. At some time

during adolescence, 22% of tile boys were

unhappy about certain aspects of their

physiques tilat the authors describe as

“sexually inappropriate,” for example,

de-velopment of the breast, size of genitals,

scanty Ptliic hair, fat hips, and facial

blem-ishes.

J

ones and Bayley17 reported that

two-thirds of the adolescents tiley studied

ex-pressed a desire for some change in their

physique. Other studies revealed that late

maturing boys are more likely than their

early-maturing peers to encounter a

gener-ally unfavorable sociopsychological

environ-ment resulting in an adverse effect on their

1)ersonality7 adaptations through a

disturb-aice in body-image.

CASE 202: E. was first seen at 13 years

of age because of ilis being “Iligh strung,

impatient, and talking incessantly”. He was

a disruptive influence in class, with a variety

of attention-seeking devices. He fought

constantly with his younger sisters and

could not get along with his age mates. He

was interested in playing ball, but his

co-ordination was so poor that once again

he was rejected. His I.

Q.

was 158,

indicat-ing a remarkable mental capacity; however,

his school grades and the Rorschach test

indicated that his intellectual efficiency was

far below this capacity.

He was 54% in. (138.4 cm) tall and

weighed 65 lb (29.5 kg), thereby being in

the 10th percentile. The marked

discord-ance of maturation (chronological age, 13

years; intellectual age, 20 years; median

height age, 9% years; and genital

develop-ment, prepubescent) was an important

fac-tor in creating conflicts. Initially, when

questioned directly, he denied concern over

his height, lack of muscular development

and prepubertal status. Continued clinical

observations, however, revealed adaptations

and defenses to a disturbed body-image,

which were reaffirmed by the Rorschach

and Draw-a-Person tests. The structure of

the body-image was determined by his

evaluation of his body, internalized earlier

psychological factors, feeling of rejection

by his age mates, and failure to achieve the

ideal body-image.

E. was seen in psychotherapy at weekly

intervals during the next 6 months, during

which time the pediatrician gave him oral

androgens to stimulate sexual maturation

and growth in

height.

He responded well

to treatment and made an excellent social

and academic adjustment in high school.

The hormones induced a growth spurt and,

although his ultimate height was not

af-fected, it did induce an earlier pubertal

spurt.

However, not all adolescents with actual

defects in maturation have a body-image

disturbance.19

CASE 203: P. was first seen at 16 years of

age in the endocrine clinic because of

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533 in. (135.9 cm) tall, which was below

tile 1 percentile level (height age, 10% years).

He presented no personality problems that

were discernible to the examining

physi-cian. He had an average intelligence.

Ac-cording to the family and the patient, he

had accepted his immaturity and short

stature, feeling that he “will grow in the

future,” based on his father’s assurance that

he also had been short until 18 years of age.

He functioned well at home and school.

He was seen irregularly during the next 5

years, with puberty beginning at 17 years

of age and fully developed when last seen

at 21 years of age when he was 64 in. (162.6

cm) tall and weighed 94 lb (42.6 kg), plac.

ing him on the 10th percentile.

Internalized Psychological Factors

We must keep in mind that it is the

per-sonality which experiences the perceptions

and creates tile concepts which make up

the body-image. Thus the previous

emo-tional experiences influence the individual’s

observations and interpretations.

Body-image is a condensed representation of the

individual’s current and past experiences of

his own body, botil real and fantasied. It

has both conscious and unconscious aspects.

Although most of the essential

compo-nents of the personality do take shape

dur-ing childhood, their interrelationship is not

fully established until late adolescence.20

Some of tile components we must evaluate

are tile individual’s concept of his own

im-portance, his aspirations for

self-enhance-ment, the sources from which he desires

status; the degree of independence

charac-terizing his relationship with others, his

method of assimilating new values, his

con-cepts of his own capacity for doing things

for himself, ilis self-esteem and feelings of

security, ilis ability to withstand frustration,

ilis ability to judge himself realistically, his

need for pleasurable and immediate

grati-fication, ilis sense of moral obligation and

responsibility, and tile type of defenses he

uses when his security or self-esteem are

threatened.

During childhood these components are

aligned according to the capacities of the

ciuld and the demands and needs of

child-hood. With puberty tile alignment is

dis-rupted, creating confusion in the person’s

modes of response. Before the individual

can be comfortable in an adult world he

must realign tile components of his

per-sonality and create a new equilibrium, a

new picture of ilimself. It seems logical to

suppose that puberty which ushers in such

a tremendous change in tile anatomic and

physiological structure of the body with

consequent emotional reactions would also

bring with it modified attitudes toward the

body. The first sign of psychological change

is probably an increased pressure toward

maturation.2’ Very shortly, the more

ag-gressive attack on life problems, the need

for independence from parental control, the

striving for maturity, and the struggle for

heterosexual adjustment become fused into

the so-called typical behavior of the

adoles-cent. Many adolescents are somewhat

over-wilelmed for a silort period by tile effects

of tile physiological maturing process, so

that some degree of body-image disturbance

frequently results.

It was apparent tilat the adolescent who

lacked relative stability as a child due to

disturbances of parent-child relationsllip,

prolonged illness, and problems of

adjust-ment, frequently failed to develop a

whole-some frame of reference for self-concept.

When such an adolescent was called on

to integrate tile changes in body

struc-ture inherent in even normal pubescence,

he experienced greater anxiety than those

who were well-adjusted. Tile less effectual

his adaptations were in early childhood,

the poorer were his adaptations to even

normal adolescent body changes or minimal

deviations in maturation and body

con-figuration. Where the maturation actually

deviated from tile normal, strong reactions

were noted to the disturbance of

body-image.

CASE 16: C. was overprotected and

in-fantilized by his mother and sisters because

of repeated attacks of rheumatic fever as

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ARTICLES

and he use(1 evei-’ possible excuse to avoid

attending. H is mother fostered

hypochon-dna and dependency. He had no friends

and spent a great deal of time with her.

Although he had been obese since 11 years

years of age, gynecomastia first developed

at 13 years of age and progressively

in-creased for tile next 2 years. He was first

seen at 16 years of age, after a boy had

“grabbed” his i)reasts and taunted him.

Following this he progressively withdrew

from swimming and then became a school

truant, finally running away from home. He

expressed extreme hostility toward his

father, projecting all the responsibility for

his gynecomastia toward him “because I

look like him”. Always dependent on his

mother, he became even more passive and

5ul)missive. His I.

Q.

was 102. A Rorschach

test revealed a passive, dependent,

emo-tionally immature person witil a

predomi-nantly homosexual orientation. Tile patient

appeared to he markedly withdrawn and

isolated from his environment, with poor

capacity for making rapport and very little

desire to become involved in emotional

re-lationships. He spoke of himself being a

hermaphrodite, winch he defined as being

upper half woman and lower ilaif man”.

The structure of his body-image was

deter-mined I)y his evaluation of his appearance

after his rejection by age mates and the

emotional instability of childhood created

by the distortion of mother-child

relation-ship. He was observed for 2 years, but he

refused surgery and failed to come

regu-larly for psychotherapy. He attempted to

resolve his problems by enlisting in the

army at 18 years of age but was silortly

dis-charged because he was “emotionally

dis-turbed. He finally married an older and

domineering woman because “she would

take care of me.”

Physical abnormalities which may have

been present since childhood develop a

new significance in adolescence.

CASE 75: L. had been obese since 11

years of age without apparent concern until

15 years of age when he “became aware”

that his configuration was different than

tilat of the other boys ill his class. He saw

them maturing and virile and himself

stay-ing flabby and immature. He was

particu-larly concerned with the fatty pectoral

pro-tuberances. He refused to attend physical

training classes or undress for showers,

being intensely disturbed by his

body-image. Tile structure of ilis body-image

was determined by his evaluation of his

appearance and a failure to achieve the

ideal body-image achieved by his age mates

as well as his feeling of being rejected by

iiis age mates because of his configuration.

He was in psychotherapy at weekly and

later less frequent intervals until 17 years

of age, with marked changes in his

atti-tudes toward himself so that he was able

to co-operate vitii tile dietician to lose

weight as well as to learn to cope with

other reality situations. The fatty

protuber-ances disappeared with loss of weight. He

was last seen at 18 years of age as a mature

individual with relatively good personality

adjustment.

REMARKS: Every adolescent ilas a need

for a sense of ilis own worth and anything

that tends to make him feel inadequate or

inferior is apt to be met promptly with

some kind of defensive reaction. Our

find-ings agree with those of Ackermanll in

that behavioral aberrations in both boys

and girls in tile second decade of life are

frequently caused by an inadequate

adjust-ment to tile feeling of being different. To

a cilild, being different usually implies

being inferior.

Adolescents with a variety of personality

disorders manifested their psychopathology

through distortions of body-concept. Some

expressed their feelings of smallness or

inferiority of self as compared to tileir

father through unrealistic concern over tile

size of their penis, others saw the minimal

pubertal hyperplasia of the breasts or delay

in onset of puberty as evidence of

actuali-zation of a castration anxiety. Schizophrenic

patients in turn may express their disturbed

body-concept through somatic delusions.

Other adolescents may project basic

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850

social inaptness to minor deviations in

physical development without actual

dis-turbances in body-image. Emotional

dis-turbances may cause developmental

defi-ciencies such as obesity, dwarfism, and

de-layed puberty.

Sociological Factors

An individual in the course of his

devel-opment is exposed to a variety of pressures

from his environment and learns to adjust

or adapt himself to them. Both the

pres-sures and the adaptation occur in a social

environment, so that the person is at the

same time exposed to the reactions of others

and by implication, their evaluation of him,

on the basis of which the individual may

alter his behavior or reinforce it. At times

the stress in the environment triggers a

“feed-back mechanism” whereby primary

tensions are fed by secondary ones often

leading to a vicious cycle of reverberations.

The attitude of the parents or parent

substitutes impart an indelible impression

on the child’s concept of himself-his body

and its functions. From earliest infancy,

the mother conveys her attitude toward her

child’s body by the way she holds him,

feeds him, touches him, and attends to his

needs. Later her approval or disapproval

is also conveyed verbally. Bruchl3 presents

a concise conceptual model of how parental

attitudes are transmitted to the child.

The child’s assessment of his body

re-fleets the values of those who take care of

him. Children who are accepted by their

families usually neither over-evaluate nor

under-evaluate their bodies. On the other

hand, when the child feels that his body

fails to come up to the expectations of

those about him he frequently develops

self-deprecatory feelings.

In turn families which tend to exploit the

significance of the body’s appearance and

function often convey to their children an

overevaluation and reliance upon security

through the “body beautiful” or “muscles”.

Adolescents with such security reliances are

less able to accept or adapt to any

devia-tion in body configuration than the

adoles-cent who has been taught by his family to

respect the uniqueness of the individual.

Parents have often created the

adoles-cent’s initial anxiety about his sexual

ade-quacy by a look, a statement or intensive

persistence in their concern over their son’s

genital status or height, or their daughter’s

delayed menarche or excessive weight,

transferring their own feeling of inadequacy

to their children. But, at times, their attack

may be unconsciously malicious and

di-rected toward satisfying their own

psycilo-pathological 24 We must remember

that unconscious motivations of parental

behavior toward the child may be in

con-trast to the conscious ones creating further

confusions to both the adolescent and the

parent.

CASE 7: C. was first brought to the clinic

by his mother when he was 1 1 years of age

because of her concern “that his penis was

too small”. However, when examined it was

noted that his genital status was well within

normal limits. When questioned, she

ex-pressed concern that her son “would grow

up like his father”. In interviews that

fol-lowed, she complained that she derived no

satisfaction from her marriage and blamed

it on the fact that her husband was

“in-adequate”. However, it was apparent that

she herself felt sexually inadequate but

could not face the fact. When G. was born

she was elated and was prepared to derive

“all her satisfactions” from her relationship

to her son; again, she was destined to be

disappointed, and unconsciously she once

again

projected the blame this time on to

her son. It was obvious that her concern

over her son’s genital status was merely a

symptom of her own psychopathology. With

the advent of puberty at 15 years of age,

G.’s penis grew, and secondary sexual

cilar-acteristics developed well within the upper

level of normal. Yet at this point the patient

himself for the first time became concerned

over

his genital adequacy. The disturbed

body-image reflected criticisms of his

mother.

REMARKS: Many of the youngsters we

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ARTICLES

the category investigated by Bruch.25 She

stated that the “outstanding pathogenic

factor in the families of these obese

chil-dren is the fact that the child is used by

one or other parent as a thing, an object

wilose function is to fulfill the parents’

needs, to compensate for their failures and

frustrations in their own lives. Tile child is

looked upon as a precious possession to

whom is offered the very best of care.” The

over-protective measures which inhibit the

development of muscular skills and

inter-fere with adequate social learning and the

excessive feeding are part of this “special

care”. Many parents openly express their

dissatisfaction with the sex of the child

be-cause the other sex would have better

ful-filled their hopes and dreams. The severe

confusion in sexual identification, so

char-acteristic of this group of obese boys

par-ticularly, can often be directly traced to

such unfortunate parental attitudes.

When deviant maturation and

inappro-priate sexual development does exist, it

may intensify and further complicate a

previously existing hostile parent-child

re-iationship. The anxiety associated with this

inappropriate sexual development is

super-imposed on and interwoven with previous

and current frustrations of his need to be

loved for ilimself regardless of his

appear-ance. The adolescent may feel that

unre-lated difficulties are caused solely by his

disfigurement.

Adolescents show extraordinary

sensitive-ness concerning their concept of self. They

react with instant responsiveness to what

they think of themselves and what others

tilink of them. Since their image of self is

in a state of flux, they are especially

vulner-able to other persons’ judgments. The issue

of whether one is approved or disapproved

by others assumes a critical importance.

More important than the objective

handi-cap of inappropriate sexual development is

the social disadvantage at which it places

tile deviant adolescent. Deviancy from the

group elicits a higilly negative response

from ins peers and almost guarantees that

he will be treated unlike his fellows.

Ado-lescents accord highly discriminatory

treat-ment to persons with physical handicaps.

Such persons enjoy lower status in the

group, are frequently ostracized, fail to

re-ceive their share of attention from the

op-posite sex, and are often treated with open

contempt and hostility. Adolescents take

competitive advantage of the shortcomings

of their rivals in the race for status in the

group and for favor in the eyes of the

op-posite sex. The individual’s response to his

own maturational deviation is largely a

reflection of the social reaction to it.

Dur-ing adolescence, when he is so dependent

upon a peer group for status, he tends to

accept the value that the group places on

him as real.

The advertising media, magazines,

mov-ies, television, and hero worship of athletes

have by direct or indirect means contributed

also to glorifying the ideal body and

de-grading the deviant.

The physician in turn through his

atti-tudes may reinforce the anxieties of the

adolescent. He must be particularly careful

in assessing the status and prognosis of

individuals in the extremes of normal

mat-uration.26

Attitudes Derived from Observing Others

Attitudes toward the body also derive

from the individual’s perceptions,

compari-sons, and identifications with the bodies of

other persons, both real and fantasied,

creating, a concept of the ideal body.27

Throughout his childhood, his family,

physician, and society had been weighing

him, taking his height, and calling attention

to how he compared to others. Now the

adolescent finds himself inadvertently

con-tinuing to compare his physical status with

that of his age mates. The advertising media

add to this stress by over-emphasizing

un-realistic ideals to which the adolescent

finds that he is comparing himself.

Another source of self-identity that

de-velops is the ego-ideal, the abstract concept

of who the person strives to be. To the

adolescent the ego-ideal of childhood based

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BODY IMAGE

same sex and the conceptualization of the

ideal by the parent of the opposite sex often

fails as a model of what he, as an

individ-ual, would like to be, since to attain

mdi-viduality he must be different, creating an

amorphous self-concept.

Illustrating tiliS problem is the frequently

unrealistic complaint of the neurotic male

that he has a small penis. He may

experi-ence his penis as small despite the fact that

its size falls within the normal range.28 In

working therapeutically with such an

mdi-vidual, we often discover that his distorted

perception of the penis involves a special

sort of relationship between the father

figure and himself which emphasized

small-ness or inferiority of the self and superiority

of the father.

CASE 204: A. was first seen at 18 years of

age because of an intense hostile aggressive

adolescent reaction. He was defiant to all

authorities and extremely belligerent to his

parents. However, his adaptations at school

continued being good, both socially and

academically. When interviewed, he made

no reference to any body-imag

disturb-ances. However, in the “as if mirror”

draw-ing of ilimself, he indicated a very small

penis. When he was directly questioned he

became very agitated and then stated that

lIe felt that his penis was “so small”.

How-ever, examination revealed a fully

devel-oped normal penis possibly on the lower

range of normal. In the sessions that

fol-lowed, he revealed a great deal of

psycho-pathology directed to his body-image. The

boy repeatedly expressed concern over the

fact that he would never be able to be as

successful as his father, or as effective as his

father or as “big” as his father. In his earlier

adolescence he constantly asked his father to

stand back to back with him to see if ile

were taller. Tile fact that he never attained

his father’s height only upset him more. It

is not unusual for adolescent boys in this

situation who may have been overwhelmed

by an early childhood memory of the size

of his father’s penis to project their feelings

of inadequacy to the size of their penis. He

then turned to muscle development

exer-cises and successfully challenged his father

repeatedly to hand wrestling.

During this period in which the ego-ideal

is so unstable, the adolescent may feel very

anxious and turn to his own age group. The

gang is just one of the many examples of

the effort of adolescents to find a

satisfac-tory self-image through an interchange with

others struggling for the attainment of the

same goal. However, the demands for

con-formity within the social group create

fur-ther stress to the discordant developed

adolescent.

MANAGEM ENT

The pediatrician should evaluate the

at-titudes of the adolescent to his body at the

time of his physical examination, whether

this examination be routine, associated with

an illness, or because of a heilavior or

emo-tional disturbance. The interview should be

structured along the lines suggested by

Levy.5 At the end of the usual physical

ex-amination, while the youngster is still

un-dressed, ile should be asked to take the

part of the physician and examine his own

body. His comments are elicited on what

he notices about the various parts of his

body and on any observable differences

be-tween himself and others, and how he

would like to see his body parts when he

is fully grown. Then he is asked how he

feels about such things as his height,

weight, strength, and looks, as well as the

secondary sexual characteristics. Here he

is encouraged to discuss sex differences and

sexual activity as he understands it. During

the interview, the pediatrician should help

mitigate the adolescent’s concern by

allow-ing him to air his anxieties and concern

over his development and answer all his

questions directly and honestly. This

“psy-chiatric-physical” is not a substitute for the

psychiatric interview but opens areas for

the subsequent psychiatric interview if

in-dicated.

To help in evaluating the attitudes of the

individual to his body-image, the

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person” and then “draw a person of the

opposite sex.” This may be helpful since

tile drawings are often a projection of

them-selves. 2)) However, many patients do not

reveal their attitudes toward their bodies

because of what Cappon3#{176} calls a “veil of

inhibition,” so that recently I have modified

this test. Tile patient is asked to stand in

front of a large sheet of wrapping paper

tacked to a door, longer than he is, and

“make believe that it is a mirror.” He is to

pretend he has just come out of the shower

and is looking into the mirror completely

nude, and then pressured to draw in

de-tail what he thinks he looks like. The

amount of pressuring varies and may

in-elude sucil statements as “I cannot tell

whether it is a boy or a girl,” “how about

the chest?”, “don’t you have any scars?”,

“are ou so thin?” The final picture is often

revealing of tile adolescent’s body-image.

\\Then an adolescent reveals a disturbance

of ilis body-image indicating anxiety over

sexual adequacy, the pediatrician should

evaluate whether the physical status truly

warrants concern, from the standpoint of

the needs and drives of the individual

adolescent and not merely statistical

devi-ations from the median.

Where deviations of physical maturation

actually exist, tile pediatrician must assess

their effect on the body-image and the

dis-tortions in personality and adaptations

created by this disturbed body-image.

De-viations suggestive of inappropriate sexual

development are particularly prone to

dis-turbances of body-image in the adolescent.

If no actual deviation exists, or where

tilere is minimal deviation but exaggerated

concern and disturbance of body-image, tile

pediatrician has to evaluate tile other key

factors vhicii contribute to tile

organiza-tion of tile I)Ody-image. It is important to

remember in working with delinquents,

school failures, behavior disorders, and

psychoneurotic reactions, including

psycho-somatic illnesses, that the disturbances of

body-image may have played an important

role in creating unacceptable patterns of

adaptation.

In other cases the disturbance of

body-image

is a result of a disturbance in

body-concept

and

somatic

delusions

due

to the

inherent psychopathology. It is imperative

for tile pediatrician to realize that there

are many youths who rationalize basic

in-adequacies by projecting their anxieties and

lack of social success onto an apparent

physical defect without actual disturbance

of the body-image. These patients require

intensive psychotherapy and are beyond

tile scope of the pediatrician.

Management of the adolescent’s disturbed

body-image brought on by any deviations

of physical maturation or the presence of a

physical defect requires more than

psycho-therapy alone or medical and surgical

treat-ment alone. What is needed are the

in-tegrated services of tile pediatrician, the

psychiatrist, the endocrinologist, and at

times the gynecologist, the plastic surgeon,

or

the dermatologist. The physican dealing

with adolescents should have a good

under-standing of all of these areas.

It is equally important for the child

psychiatrist to understand that it is

impera-tive for him to obtain the help of his

col-leagues in the otiler specialties to cope with

an

adolescent

who

has

an emotional

dis-turbance or a behavior disorder who has

any associated physical defect or

disturb-ance of physical maturation.

The adolescent is very much concerned

about his body and wants his physician to

take his worries seriously. Naturally, he

will resent it if the physician just “shrugs

it off.”31 Nor is it enough to assure an

adolescent that he is within the statistical

limits of normal, or to tell him that there is

nothing that can be done about his

condi-tion or tllat ile will “outgrow it.” What the

adolescent requires is repeated reassurance,

continuing interest, and help, so that he

may understand the vast difference between

being abnormal and not being average. He

must learn to cope with reality factors in

his disturbed body-image. If the defect can

be modified, it should be done through

whatever means are available, hormones,

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exer-854

cise. Often when the adolescent must

as-sume an active role in the treatment, such

as maintaining a diet or exercising, the

un-conscious drives and defense mechanisms

prevent him from co-operating, requiring

psychotherapy. If the defect cannot be

modified, the only thing to do is to foster

in the patient an acceptance of himself.

Like the psychiatrist, the

psychiatrically-oriented pediatrician is called on to nurture

and encourage a realistic and wholesome

adaptation to the actual defect and

dis-turbed body-image and work through the

infantile and childhood conflicts that may

have predisposed the adolescent to the

in-tensity of his reaction. If the defect has

a!-ready been modified, then it is up to the

physician to help the adolescent develop a

more satisfying body-image and reconstruct

ilis patterns of adaptation.

CONCLUSIONS

The pediatrician must accept an active

role in the management of the emotional

and behavioral problems of the adolescent.

The body-image concept is the natural

domain of the pediatrician since he is in

the best position to evaluate the individual’s

attitudes and appraisal of his own physical

appearance. By understanding the factors

which are involved in determining the

“structure” of the body-image, namely, the

individual’s actual appearance, the

inter-nalized psychogenic and the sociological

factors and their concept of the ideal, the

pediatrician can help both the parents and

the adolescent to understand their needs

and develop acceptable adaptations.

The body-image as a psychiatric concept

has validity at all ages but can be of

par-ticular help to understand the problems of

the adolescent in whom the body takes on

a new significance. There can be no doubt

that in adolescence anatomic, physiological,

and psychological disharmonies do take

place. The pediatrician is often the one

who is called on to interpret their meaning

to the adolescent as veil as tile parents in

order to prevent unhappy consequences.

The patient must learn to understand and

accept himself. For their own future

happi-ness and well-being, we need somehow to

foster in these young people the idea of

the uniqueness, the dignity and the worth

of the individual.

REFERENCES

1. Schonfeld, \V. A. : Pediatrician’s role in the management of the personality problems of

adolescents. Amer. J. Dis. Child., 81:762, 1951.

2. American Academy of Pediatrics and Corn-munity Council of Greater New York: The role of the pediatrician in the prevention of delinquency (summary of a conference).

PEDIATRICS, 24:822, 1950.

3. Schilder, P. : The Image and Appearance of

the Human Body: Studies in the Construe-live Energies of the Psyche. London, Kegan, Paul, 1935.

4. Koib, L. C. : Disturbance of the Body-Image;

Chapt. 38 in American Handbook of

Psy-chiatry; edited by S. Arieti. New York,

Basic Books, 1959.

5. Schilder, P. : Psychoanalysis, Man and So-ciety. New York, Norton, 1951.

6. Koib, L. C. : The body image in

schizo-phrenic reaction; in Schizophrenia, an Integrated Approach; edited by Alfred

Auerback. New York, Ronald Press, 1959.

7. Schonfeld, W. A. : Body-image disturbances

in adolescents with inappropriate sexual

development. Amer. J. Orthopsychiat.

Ac-cepted for publication.

8. Levy, D. M. : Method of integrating physical

and psychiatric examination with special

studies of body interest, overt protection, response to growth and sex differences. Amer. J. Psychiat., 9:121, 1929.

9. Stuart, H. C. : Normal growth and develop-ment during adolescence. New Engl. J. Med., 234:666, 693, 732, 1946.

10. Schonfeld, W. A. : Primary and secondary

sexual characteristics. Amer. J. Dis. Child.,

65:535, 1943.

11. Curran, F.

J.,

and Frosch, J.: The body

image in adolescent boys. J. Gen. Psych.,

60:37, 1942.

12. More, M. : Development concordance and

dis-cordance during puberty and early

ado-lescence. Monograph 56 of the Society for

Research and Child Development, 1953.

13. Schonfeld, W. A. : Gvnecomastia in

adoles-cence-personality effects. Arch. Psychiat., 5:46, 1961.

14. Schonfeld, W. A. : Gynecomastia in adoles-cence-effect on body-image and personality adaptations. Psychosom. Med., 24 :379, 1962.

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superego development. Amer.

J.

Orthopsy-chiat., 18:636, 1948.

16. Stolz, H. R., and Stolz, L. M. : Adolescent

problems related to somatic variation; 43rd

Year Book; National Society for the Study of Education; Part I; Adolescence. Chicago,

University of Chicago Press, 1944, pp. 80-97.

17. Jones, M. C., and Balgley, N. : Physical ma-turing among boys as related to behavior. J. Educ. Psychol., 41:129, 1950.

18. Mursen, P. E., and Jones, M. C. :

Self-con-ceptions, motivations and interpersonal attitudes of late and early maturing boys.

Child Develop., 28:243, 1957.

19. Caplan, H. : Some considerations of the

body-image concept in child development. Quart.

J.

Child Behavior, 4:382, 1952.

2#{216}Stevenson, I. : Is the human personality more

plastic in infancy and childhood? Amer.

J.

Psychiat., 1 14: 152, 1957.

21. Josselyn, I. M. : The Adolescent and His

World. New York, Family Service Associa-tion of America, 1952.

22. Ackerman, N. W. : Adaptive Problems of the

Adolescent Personality: The Family in a

Democratic Society. New York, Columbia

University Press, 1949.

23. Bruch, H. : Falsification of bodily needs and

body concept in schizophrenia. Arch. Gen.

Psychiat., 6: 18, 1962.

24. Johnson, A. M. : Juvenile Delinquency; in

American Handbook of Psychiatry, Vol. 1.

New York, Basic Books, 1959, p. 845.

25. Bruch, M. : Weight disturbances and

Schizo-phrenic development. Report of the lind

mt. Cong. for Psychiatry (Zurich,

Switzer-land), 2:190, 1957.

26. Gallagher,

J.

R. : Problems of the Adolescent.

Pediat. Clin. N. Amer., 5:775, 1958.

27. Josselyn. I. NI. : Psychology of Adolescents; in

Readings in Psychoanalytic Psychology; edited by Morton Levitt, New York, Apple-ton-Century-Crofts, 1959, p. 79.

28. Schonfeld, W. A.: Management of male

pubescence. J.A.M.A., 121:177, 1943.

29. Machover, K.: Personality Projection in the

Drawing of the Human Figure. Springfield,

Illinois; Thomas; 1957.

30. Cappon, D. : Study of the relation between

fantasy and bodily illness. Unpublished

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1963;31;845

Pediatrics

William A. Schonfeld

PEDIATRICIAN

BODY-IMAGE IN ADOLESCENTS: A PSYCHIATRIC CONCEPT FOR THE

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Pediatrics

William A. Schonfeld

PEDIATRICIAN

BODY-IMAGE IN ADOLESCENTS: A PSYCHIATRIC CONCEPT FOR THE

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