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 bypsychi-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
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.
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 thattwo-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 wellto 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
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
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 Rorschachtest 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
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 toher 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 disturbedbody-image reflected criticisms of his
mother.
REMARKS: Many of the youngsters we
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
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
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 inbody-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 dealingwith 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,
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 bodyimage 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.
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