Body Image: The Inner Mirror

James W. Breakey, PhD, CP

ABSTRACT

Each individual holds an idealized mental picture of his or her physical self; he or she uses this image to measure concepts related to body image. Once an individual's percepts or concepts of this body image are altered, emotional, perceptual and psychosocial reactions can result.

Psychosocial well-being often is affected by such factors as anxiety and depression, concerns with self-esteem, and satisfaction with life. In the general population, a person's positive or negative feelings toward his or her body have been found to affect his or her well-being.

Living in a society of mostly able-bodied persons, individuals who have disabilities must contend with comparing the appearance of their bodies and functional capabilities to those of others around them. Mental health practitioners often see physical deviation from the norm as central to people's behavior and personality.

The following article strives to provide prosthetists and orthotists with insight into the relationship between body image and psychosocial well-being.

Key words: Amputee; Psychosocial; Body Image; Self-esteem.

Introduction

American society is preoccupied with the perfect human form. Anyone who deviates from this ideal image is labeled different. Many relatively normal individuals have difficulty dealing with this issue of body appearance. In essence, whether a person is overweight or underweight or has a large nose by society's standards is not the determining factor in psychological health; instead, how a person perceives his or her physical uniqueness influences his or her subjective well-being.

Knowledge about the self is established primarily through sensory experience and perceived viewpoints of others. As a result, the body may become invested with significance well beyond its functional capabilities. Because a person's physical appearance is his or her calling card, it is reasonable to hypothesize a significant relationship would exist between our evaluations of our bodies and our subjective well-being.

Body image is the mental picture a person forms of his or her physical self. According to Kolb (1), each individual holds an image of the body that he or she considers the ideal in relation to his or her own body. An alteration in a person's body image sets up a series of emotional, perceptual and psychosocial reactions (2). Loss of a limb through amputation will, Kolb suggests, probably lead to a long-term disorder in body experience (2).

The perceived discrepancy between the altered physical state (e.g., caused by a mutilating injury) and the former physical state produces emotional tension (3). This tension is experienced as anxiety, which becomes chronic as long as the discrepancy continues (3).

Results have led to a better understanding of ill-being--specifically, anxiety, depression and unpleasant emotions. Research has been conducted on the construct of subjective well-being (4,5). Two broad aspects of subjective well-being have been identified: an affective component, including pleasant affect and unpleasant affect (6); and a cognitive component (7), referred to as life satisfaction.

In their extensive body-image survey, Cash et al. (8) included several items they identified as comprising psychosocial well-being. The items addressed self-esteem, life satisfaction, depression, loneliness and feelings of social acceptance. Persons with positive evaluations about their body image reported favorable psychological adjustment. In contract, those with negative feelings presented lower levels of psychosocial adjustment (8).

Single characteristics have the power to evoke a wide range of feelings and impressions about a person (9). This concept, called spread, suggests physical deviation from the norm is frequently the key to a person's behavior and personality. Furthermore, such deviation can be largely responsible for many important developments in the life of a person with a physical disability (10). The concept of spread is valid both for someone who has a disability and for those evaluating that individual. Some may view the disabled individual as less worthy and less capable. The individual also may take this view. Thus, physical form may affect self-perception of an individual's capability as well as his or her acceptability to others.

Those who have disabilities often must contend with the effects of stigmatization. Stigma refers to an attribute, either physical or psychological, that makes a person different from others and therefore less desirable (11). Considering the stimulus that a person presents and the feedback received purely on the basis of physical appearance, it is conceivable that others' reactions to a newly disabled individual may influence how the individual perceives him- or herself. For instance, if the response is negative, the person may begin to view him- or herself as deformed, incompetent and inferior. A comparison of his or her body appearance and capability with those of others, combined with the potential effects of spread and stigmatization, may lead him to a negative body image, which also may affect his or her subjective well-being.

A person who has lost a limb through amputation tends to compare his or her appearance and functional capabilities to others', the majority of whom are able-bodied. Based on these comparisons, one could speculate it would be difficult for an individual who has a disability to develop a positive attitude with respect to his or her body.

Review of the Literature

Body Image

Body image is one's psychological picture of the physical self. The noted neurologist Sir Henry Head was the first to describe the concept of body image. This image, or body schema, is a unity of experiences of the past, coupled with present body sensations, which are organized in the sensory cortex of the cerebrum (12). Each individual develops this body schema: a model or self-picture that can be compared to others in terms of body postures and body motions (13). Body experience is important to normal psychological development and behavior (12).

Body image is more than a reference model; it also has emotional and symbolic significance (14). Schilder defines body image as the picture of our own body which we form in our mind (14). Practicing as a psychiatrist, he realized distortions in body experience attributed to brain pathology needed to be studied not only from the perspective of brain physiology but also from the psychological viewpoint. The many variables associated with body image have principal relevance in both the pathological aspects of daily life and in ordinary everyday events. Because body image lies at the center of personality, body experience is the nucleus of psychological life (14).

Further, body-image development is influenced by several factors:

optic and tactile sensations;
emotional experiences and their influence on the relative value one has for the multifaceted body image;
social experiences, with ongoing interchanges between the impressions others have about our physical appearance and our personal reactions to these impressions; and
our own attitudes and values we place on our bodies as derived from comparisons wi>th others, our own introspection, and past positive and negative experiences (14).

Body image is capable of extending beyond the physical boundary to envelop external objects such as clothing or a walking stick. The more rigid the connection of the body with the object, the more easily it becomes part of the body image (14). In summary, body image as defined by Schilder is the picture of our body we form in our minds as tridimensional units, including interpersonal, environmental and temporal factors (1).

According to Fisher and Cleveland (15), Freud considered body image instrumental to ego development; Fisher and Cleveland agree with Schilder that personal symbolic significance can be attributed to body regions. Sensations from body regions to which an individual is especially sensitive arouse attitudes proportional to the psychological significance placed on the body part.

Similarly, the more a person accepted his body, or liked it, the more secure and free from anxiety he felt (16). Therefore, Jourard postulates, a high degree of body cathexis [ratings of body parts] would contribute to an individual's acceptance and approval of his or her own overall personality. Evaluative feelings about the body affect the individual's psychosocial, social and physical exchanges with the environment (17). The degree and direction of one's feelings toward the body are related to anxiety, insecurity and stability. There is a high correlation between body cathexis and self-cathexis (ratings of aspects of self).

A relationship exists between the body's personal security, mitigation of anxiety and positive feelings of self-esteem. Personal appearance is a means to many highly valued ends in our society, and, if a person is not physically attractive or perceives him- or herself as unattractive, his or her access to these goals is diminished, leading to anxiety and a general self-devaluation (17).

The concept of body-image boundaries is an important dimension of the body image (15). In normal perceptions, an individual's body limit or boundary is unconscious and allows a sense of a fixed separation from the external environment. Using projective tests, such as Rorschach or Holtzman ink blots, perceived body boundaries may be studied (15). More specifically, Fisher and Cleveland report on a method they developed to sense perceived boundaries using ink blots. Their method assessed two separate responses: the barrier response (which stresses finiteness of boundaries, called barrier scores) and the penetration response (expressing indefiniteness and penetration of the boundaries, called penetration scores). Fisher and Cleveland gathered a good deal of evidence that revealed the way people picture the boundaries of their ink blot responses mirrors how they feel about their own body boundaries. The ink blot responses closely linked with body events, specifically with the psychological and physiological contrast between interior and exterior body regions (18).

Barrier scores have been found to be correlated with effectiveness in coping with the ability to adapt to insults of the body integrity. For example, barrier scores have correlated positively and significantly with effective adjustment to amputation (19).

Body awareness is another dimension of the body image. Fisher (20) describes his body prominence measure, which he has used to quantify body awareness. Subjects are instructed to list 20 things they are aware of at the moment. All references to the body or body functions are scored. The rationale for this measure is simple: The greater the focus an individual places on his or her body, the greater the number of references to the body he or she will make in the 20 things. Some people disregard body perceptions while others are tuned into their body messages. Meanwhile, hypochondriacal individuals tend to demonstrate heightened body awareness and view these sensations as threatening.

Fisher also uses another investigative tool, the body focus questionnaire, which consists of 108 pairs of body parts divided into eight scales. Subjects are asked to choose the one pair of body parts of which they are most aware. A score is derived for each of the eight scales equal to the number of times a particular pair of body parts is picked (e.g., heart or stomach). According to Fisher, an individual places a special value and symbolic meaning on body parts that tend to be unconscious and may reflect intrapsychic defenses and conflicts (20).

The disturbance of a normal body image, as occurs with an amputation, sets up a series of emotional, perceptual and psychological reactions in the individual (1). Individuals who have undergone amputation of a limb may experience anxiety and depression (1). Psychological dysfunction can result when body image changes (21) because body parts carry conscious and unconscious symbolic meaning for an individual (22). If the body image is altered, such as through limb loss, psychological and psychopathological responses can occur. Patients, including amputees, manifest body-image disturbance (3). The types of problems Henker most frequently observed were anxiety, depression, guilt, projection and scapegoating. He concluded the value placed on the lost anatomical part influences the reaction to the altered body appearance. The discrepancy between the perceived altered physical state and the former physical state produces emotional tension. This tension is experienced as anxiety, which becomes chronic as long as the discrepancy continues (3).

Body dysfunction has personal meaning for the individual who places value on the body part(s) and function(s) (21). This subjective value is the result of 1) past learning experiences about body dysfunction, either personally or from others; 2) how successful one is in coping with these experiences; 3) positive or negative reinforcement received from others about one's body appearance, skills and behavior; and 4) cultural agreement on attitudes held toward body parts.

Individuals value certain body parts or functions for several reasons: They provide a source of self-esteem or sense of competence; help contend with the environment; enhance self-concept and stability of body image; and allow the individual to continue social, sexual and vocational functioning. Sometimes the value has unconscious symbolic meaning which imparts of it a vital value. Any disability that disrupts any of these personal values will have a deep psychological effect on the individual (21).

The degree of emotional reactions to body dysfunction correlates with the subjective value and meaning placed on the body part--both conscious and unconscious--and not the severity of the pathology or lost function (23). Mitchell's study supports Shontz's position. The relationship was studied between the barrier score and the ability to adapt to spinal cord injury (24). Using Rorschach ink blots, Mitchell determined barrier scores from 50 male paraplegics and 52 male quadriplegics. Barrier scores were significantly higher in the high-adjustment paraplegic subjects than in the low-adjustment group. In contrast, the barrier score did not present any significant distinction in the quadriplegic sample between the high- and low-adjustment subjects. When the impact of a disability is so destructive, as in quadriplegia, adjustment may be a function of variables outside of self, such as outside support systems (25).

Can a value be put on different body parts? Plutchik, Conte and Weiner (26) addressed this question by asking 203 subjects to determine a dollar value that would be acceptable if a body part were lost in an accident and an insurance claim were to pay off. The largest compensations were asked for the leg, eye and arm as contrasted with lower compensations for the finger and toe. The researchers have interpreted these responses as relating to an individual's ability to function and to interact with the environment. Other findings in this study indicate no significant relationship between the dollar value placed on a body part and the age of the individual. This appears to be consistent with the earlier findings of Fisher (27), who reported older people do not differ from younger people in the properties they assign to their body boundaries.

An analysis was made of a 2,000-person sample of a 30,000-person survey of the general public on body image (8). In the general population the authors found a relationship between psychosocial well-being and body image. Seventy-three percent of women and 62 percent of men who had a negative body image were well-adjusted whereas 97 percent of women and 95 percent of men with positive images of their physical appearance were well-adjusted. The authors included several items in their survey to tap what they believed constituted psychosocial well-being. These items asked about self-esteem, life satisfaction, loneliness, depression and feelings of social acceptance (8). Persons with disabilities or disfigurement exhibited a negative reaction on perceived appearance, fitness and health. Their increase in negative body image was 12 percent in men and 20 percent in women as compared to the rest of the group.

Based on the preceding literature review, body image appears to be a construct that is a product of pertinent experiences and that can exert regulating influences on behavior. Any significant change in experience relevant to the body would be expected to produce a change in perception and evaluation of an individual's body image.

Personality and Physical Disability

Three important psychological maneuvers act on body experience (20). The first is magnification and dampening of body experience. For example, people can focus on their bodies to the point of developing hypochondriasis, or, by contrast, become celibate (as demanded by some religious groups). A second maneuver is setting up a division between self and the environment. For some people, this differentiation between the body and the external world is necessary for development of a concept of self. The third maneuver is applying attention to dominant body areas. In short, patterns of body awareness provide the groundwork for the expression of personality (14,20).

Personality cannot exist without the body image any more than a house can exist without walls (27, p. 467). In an earlier discussion on personality and the disabled, Shontz (28), p. 36) states, The term personality refers to the way in which the person with a disability integrates the behavioral facts of his disability into his total life pattern. The reaction to disability is individualized, and a person's individuality overshadows all other variables, including those of etiology and magnitude of the somatic involvement (30). In an extensive review of the literature, Shontz (23,29) found no data to support a relationship between disability and degree of adjustment--that is, there was no convincing support or the proposition that disability produces or is correlated with personality maladjustment (29, p. 49).

In support of Shontz, Wright (10, p. 240), after a review and discussion of the literature in her book Physical Disability--A Psychosocial Approach, concludes, There is no substantial evidence to indicate that persons with an impaired physique differ as a group in overall adjustment from their able-bodied counterparts. She asserts, There is no clear evidence of an association between type of physical disability and particular personality characteristics (10, p. 241).

Earlier studies indicate similar findings. For example, Fishman (31) found no reason for identifying unique personality characteristics in amputees. Tizard (32) drew the same conclusion from a literature review on the personality of epileptics. Other authors have reached essentially the same conclusion: Harrower and Kraus (33) and Cohen (34) in multiple sclerosis and Moos (35) in rheumatoid arthritis. Later, Pringle (36) reports on his extensive review of the literature written between 1928 and 1962 on the emotional and social adjustment of children with physical disabilities. He found no evidence of an association between disability and behavior characteristics or that physical disability leads to maladjustment. Another study, Weinberg-Asher's comparison of able-bodied and disabled college students (37), found no difference in the way they viewed themselves.

In contrast, a number of studies dispute the above findings. Barker et al. (38) studied severity of the disability and found significant differences in self-esteem in groups of mildly, moderately and severely disabled. Ware, Fisher and Cleveland (39) noted a significant relationship between adjustment to poliomyelitis and body image. Cowen and Brobrove (40), in a study comparing partially and totally blind children, reported marginally impaired subjects display greater personality disturbance than severely impaired subjects. In a study of amputees, Weiss et al. (41) found severity of disability did affect the personality as well as physical functioning. Matulay and Pauloukin (42) studied epileptics and found them, as a group, to show increased anxiety, low frustration tolerance and depressive mood swings.

The following conclusions may be drawn about personality and the physically disabled:

There is little evidence that particular personality characteristics are associated with particular disabilities.
There is little evidence that the age of onset of a disability and the severity are correlated with psychological adjustment.
People who have disabilities, in general, manifest different personality factors than the non-disabled. These factors include increased anxiety, increased depression and impaired self-concept.

Psychological Levels and Functions of Body Experience

In his book The Psychological Aspects of Physical Illness and Disability, Shontz (23) suggests body experience occurs at four levels: body schemeta, body self, body fantasy and body concept. His observations are summarized below.

Level 1: Body Schemeta. This is the most basic level of body experience and pertains to the perception of the body as an object in space. Amputation appears to interfere with perception at this level. Schilder (14) considers the phenomenon of a phantom limb experienced by a lower-limb amputee to be an expression of the body schemata.
Level 2: Body Self. Body experience at this level develops from and incorporates body schemata. The individual develops a body-image boundary--personal space to buffer self from the non-self. A great amount of research has been conducted at this level (15,25).
Level 3: Body Fantasy. According to Shontz (23), fantasy, while complicated, is a bountiful wellspring of information about body experience. In scoring inkblot responses, Fisher and Cleveland (15) and Fisher (20) used fantasy to determine body boundary characteristics. They used body fantasy to assess body experience. An example of this is a subject's seeing a turtle in an inkblot. The turtle's shell could be interpreted as a barrier or protection between the self and the environment.
Level 4: Body Concept. Using signs and symbols, people learn to expand their understanding and begin to express their body experience. For example, human locomotion can be referred to as normal or abnormal depending on the accumulation of knowledge an individual has about the subject. This information helps an individual to enhance his or her self-understanding and allows him or her to make comparisons between him- or herself and others.

Seven normal functions of body experiences are described by Shontz (23,28):

Acting as a sensory register, the body realizes incoming sensation, interprets and integrates the information, and files the data for retention.
In response to stimuli, the body can respond as an instrument for action. This action can be as simple as a primitive reflex or as involved as jumping out of the way of an oncoming vehicle.
Humans come equipped with a source of drives adequate to assist survival. Additional needs are generated by learning. Bodily drives usually are automatic, such as hunger or thirst, whereas social drives are learned.
As a stimulus to the self, the body serves as a reference for self-identity. The body is heavily endowed with significance to be evaluated in relation to others.
Because the body self is greatly influenced by social values, it acts as a stimulus to others. As a result, the response from others can cause an individual to evaluate him- or herself in those terms. Physical appearance is a definite social stimulus.
The body offers a private world for the personal self to exist. Shielded by one's physical boundaries, a place of private expression is available, unique and impervious to others.
Besides being a protective shell, the body is a vehicle or an expressive instrument for individual expression. Countless and elaborate expressions are encountered daily in body language seen between interacting individuals.

Later, Shontz (43) affirms the levels and functions of body experience are integrated, as is any structure system, e.g., a corporation. Integration is mandatory if a person is to prevail and individuate. Body experience and personality operate together. If the body is disturbed, the personality or self is affected to some degree and vice versa. Most body functions are taken for granted, but when they are interfered with by illness or disrupted by disability their importance becomes more apparent to the individual (23).

Conclusion

The implications of one's perception of body image is important. Generally, the initial feedback and reinforcement we receive from others is about our bodies--their appearance, how they move, etc. Early childhood experiences and later development are essential to personality development and contribute to the perception of body image. The concept of self initially evolves from sensations and perceptions from within the body and later from the perceptions of self communicated to the individual via feedback from family, friends and peer groups. Blossoming of the body image is integrated with the socialization process, which involves internalization of social standards of attractiveness, capability and normality. Individual development of a positive or negative body image is thus influenced by the perception of oneself relative to these standards. Since the body creates the first impression, eliciting a large amount of feedback on which feelings of self-esteem are built, it is understandable a relationship would be seen between body image and self-esteem.

Through the concepts of devaluation, spread and stigmatization, the psychological assault with which the individual who has a disability must contend is understandable. This individual must deal with his or her perception of the disability, the spreading of the disability to other aspects of self, and the judgment by peers and society of his or her physical appearance and capabilities. Therefore, it is easy to understand why a person's body image may very well affect his or her psychosocial well-being.

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