Development of Body Image Throughout the Life Cycle

Definition-“Mental picture of body’s appearance; an interrelated phenomenon which includes the surface, depth, internal and postural picture of the body, as well as the attitudes, emotions, and personality reactions of the individual in relation to his body as an object in space, apart from all others."

Operational definitions
1. Body image is created by social interaction.
  1. Approval given for “normal” and “proper” appearance, gestures, posture.
  2. Behavioral and physical deviations from normality not given approval.
  3. Body image formed by the person’s response to the approval and disapproval of others.
  4. Person's values, attitudes, and feelings about self continually evolving and unconsciously integrated.
2. Self-image, identity, personality, sense of self, and body image are interdependent.
3. Behavior is determined by body image.

Concepts related to persons with problems of body image
1. Image of self changes with changing posture (walking, sitting, gestures).
2. Mental picture of self may not correspond with the actual body; subject to continual but slow revision.
3. he degree to which people like themselves (good self-concept) is directly related to how well defined they perceive their body image to be.
  1. Vague, indefinite, or distorted body image correlates with the following personality traits:
    1. Sad, empty, hollow feelings.
    2. Mistrustful of others; poor peer relations.
    3. Low motivation.
    4. Shame, doubt, sense of inferiority, poor self-concept.
    5. Inability to tolerate stress.
  2. Integrated body image tends to correlate positively with the following personality traits:
    1. Happy, good self-concept.
    2. Good peer relations.
    3. Sense of initiative, industry, autonomy, identity.
    4. Able to complete tasks.
    5. Assertive.
    6. Academically competent; high achievement.
    7. Able to cope with stress.
4. Child’s concept of body image can indicate degree of ego strength and personality integration; vague, distorted self-concept may indicate schizophrenic processes.
5. Successful completion of various developmental phases determines body concept and degree of body boundary definiteness.
6. Physical changes of height, weight, and body build lead to changes in perception of body appearance and of how body is used.
7. Success in using one’s body (motor ability) influences the value one places on self (self-evaluation).
8. Secondary sex characteristics are significant aspects of body image (too much, too little, too early, too late, in the wrong place, may lead to disturbed body image). Sexual differences in body image are in part related to differences in anatomical structure and body function, as well as to contrasts in lifestyles and cultural roles.
9. Different cultures and families value bodily traits and bodily deviations differently.
10. Different body parts (for example, hair, nose, face, stature, shoulders) have varying personal significance; therefore there is variability in degree of threat, personality integrity, and coping behavior.
11. Attitudes concerning the self will influence and be influenced by person’s physical appearance and ability. Society has developed stereotyped ideas regarding outer body structure (body physique) and inner personalities (temperament). Current stereotypes are:
  1. Endomorph-talkative, sympathetic, good natured, trusting, dependent, lazy, fat.
  2. Mesomorph-adventuresome, self-reliant, strong, tall.
  3. Ectomorph-thin, tense and nervous, suspicious, stubborn, pessimistic, quiet.
12. Person with a firm ego boundary or body image is more likely to be independent, striving, goal oriented, influential. Under stress, may develop skin and muscle disease.
13. Person with poorly integrated body image and weak ego boundary is more likely to be passive, less goal oriented, less influential, more prone to external pressures. Under stress, may develop heart and GI diseases.
14. Any situation, illness, or injury that causes a change in body image is a crisis, and the person will go through the phases of crisis in an attempt to reintegrate the body image.

Assessment

Analysis/nursing diagnosis-body image development disturbance may be related to:
1. Obvious loss of a major body part-amputation of an extremity, hair, teeth, eye, breast.
2. Surgical procedures in which the relationship of body parts is visibly disturbed-colostomy, ileostomy, gastrostomy, ureteroenterostomy.
3. Surgical procedures in which the loss of body parts is not visible to others-hysterectomy, lung, gallbladder, stomach.
4. Repair procedures (plastic surgery) that do not reconstruct body image as assumed-rhinoplasty, plastic surgery to correct large ears, breasts.
5. Changes in body size and proportion-obesity, emaciation, acromegaly, gigantism, pregnancy, pubertal changes (too early, too late, too big, too small, too tall).
6. Other changes in external body surface-hirsutism in women, mammary glands in men.
7. Skin color changes-chronic dermatitis, Addison’s disease.
8. Skin texture changes-scars, thyroid disease, excoriative dermatitis, acne.
9. Crippling changes in bones, joints, muscles- arthritis, multiple sclerosis, Parkinson’s.
10. Failure of a body part to function-quadriplegia, paraplegia, cerebrovascular accident (CVA)
11. Distorted ideas of structure, function, and significance stemming from symbolism of disease seen in terms of life and death when heart or lungs are afflicted-heart attacks, asthmatic attacks, pneumonia.
12. Side effects of drug therapy-moon face, hirsutism, striated skin, changes in body contours.
13. Violent attacks against the body-incest, rape, shooting, knifing, battering.
14. Mental, emotional disorders-schizophrenia with depersonalization, somatic delusions, and hallucinations about the body; anorexia nervosa, hypochondriasis; hysteria, malingering.
15. Diseases requiring isolation may convey attitude that body is undesirable, unacceptable-tuberculosis, AIDS, malodorous conditions (e.g., gangrene, cancer).
16. Women’s movement and sexual revolution-use of body for pleasure, not just procreation, sexual freedom, wide range of normality in sex practices, legalized abortion.
17. Medical technology-organ transplants, lifesaving but scar-producing burn treatment, alive but hopeless, alive but debilitated with chronic illnesses.
General nursing care plan/implementation:
1. Protect from psychological threat related to impaired self-attitudes.
  1. Emphasize person’s normal aspects.
  2. Encourage self-performance.
2. Maintain warm, communicating relationship.
  1. Encourage awareness of positive responses from others.
  2. Encourage expression of feelings.
3. Increase reality perception.
  1. Provide reliable information about health status.
  2. Provide kinesthetic feedback to paralyzed part; “I am raising your leg.”
  3. Provide perceptual feedback; touch, describe, look at scar.
  4. Support a realistic assessment of the situation.
  5. Explore with the client his or her strengths and resources.
4. Help achieve positive feelings about self, about adequacy.
  1. Support strengths despite presence of handicaps.
  2. Assist client to look at self in totality rather than focus on limitations.
5. Health teaching:
  1. Teach client and family about expected changes in functioning.
  2. Explain importance of maintaining a positive self-attitude.
  3. Advise that negative responses from others be regarded with minimum significance.

Evaluation:
1. Able to resume function in activities of daily living rather than prolonging illness.
2. Able to accept limits imposed by physical or mental conditions and not attempt unrealistic tasks.
3. Can shift focus from reminiscence about the healthy past to present and future.
4. Less verbalized discontent with present body; diminished display of self-displeasure, despair, weeping, and irritability.

Four Phases of Body Image Crisis

Phase	Assessment	Nursing Care Plan/Implementation
Acute shock	Anxiety, numbness, helplessness.	Provide sustained support, be available to listen, express interest and concern. Allow time for silence and privacy.
Denial	Retreats from reality; fantasy about the wholeness and capability of the body; euphoria; rationalization; refusal to participate in self-care.	Accept denial without reinforcing it. Avoid arguing and overloading with reality. Gradually raise questions, reply with doubt to convey unrealistic ideas. Follow client’s suggestions for personal-care routine to help increase feelings of adequacy and to decrease helplessness.
Acknowledgement of reality	Grief over loss of valued body part, (unction, or role; depression, apathy; agitation, bitterness; physical symptoms (insomnia, anorexia, nausea, crying) serve as outlet for feeling; redefinition of body structure and function, with implications for change in lifestyle; acceptance of and cooperation with realistic goals for care and treatment; preoccupation with body functions.	Expect and accept displacement onto nurse of anger, resentment, projection of client’s inadequacy. Examine own behavior to see if client’s remarks are justified. Simply listen if this is the only way the client can handle feelings at this time. Offer sustained, nonjudgmental listening without being defensive or taking remarks personally. Help dispel anger by encouraging its ventilation. Encourage self-care activities. Support family members as they cope with changes in client’s health or body image, role changes, treatment plans.
Resolution and adaptation	Perceives crisis in new light; increased mastery eads to increased self-worth; can look at, feel, and ask questions regarding altered body part; tests others’ reactions to changed body; repetitive talk on painful topic of changed self; concentration on normal functions in order to increase sense of control.	Teaching and counseling by same nurse in warm, supportive relationship. Assess level of knowledge; begin at that level. Consider motivational state. Provide gradual, nontechnical medical information and specific facts. Repeat instructions frequently, patiently, consistently. Support sense of mastery in self-care; draw on inner resources. Do not discourage dependence while gradually encouraging independence. Focus on necessary adaptations of lifestyle due to realistic limitations. Provide follow-up care via referral to community resources after client is discharged.

Four Phases of Body Image Crisis

Age Group	Development of Body Image	Developmental Disturbance in Body Image
Infant and toddler	Becomes aware of body boundaries and separateness of own external body from others through sensory stimulation. Explores external body parts; handles and controls the environment and body through play, bathing, and eating. Experiences pain, shame, fear, and pleasure. Feels doubt or power in mastery of motor skills and strives for autonomy. Learns who one is in relation to the world.	Infant Inadequeate somatosensory stimulation-impaired development, increased anxiety level, poor foundation for reality testing. Continues to see external objects as extension of self-unrealistic, distorted perceptions of significant persons, inability to form normal attachments to others (possessive, engulfing, autistic, withdrawn). Toddler If body fails to meet parental expectations-shameful, self-deprecating feelings. Failure to master environement and control own body-helplessness, inadequacy, and doubt.
Preschool and school age	Experiences praise, blame, derogation, or criticism for body, its part, or use (pleasure, pain, doubt, or guilt). Explores genitals—discovers anatomical differences between sexes with joy, pride, or shame. Begins awareness of sexual identity. Differentiates self as a body and self as a mind. Beginning of self-concept; of self as man or woman. Learns mastery of the body (to do, to protect self, to protect others) and environment (run, skip, skate, swim); feels pleasure, competence, worth, or inadequacy.	Preschool Distortion of body image of genital area due to conflict over pleasure versus punishment. If body build does not conform to sex-typed expectations and sex role identification-body image confusion. School age Physical impairments (speech, poor vision, poor hearing)-feelings of inadequacy and inferiority. Overly self-conscious about, and excessive focus on, body changes in puberty.
Adolescent	Physical self is of more concern than at any other time except old age. Forced body awareness due to physical changes (new senses, proportions, features); feelings of pleasure, power, confidence, or helplessness, pain, inadequacy, doubt, and guilt. Adult body proportions emerge. Anxiety over ideal self versus emerging/emerged physical self; body is compared competitively with same-sex peers. Use of body (adolescents’ values and attitudes) to relate with opposite sex. Body image crucial for self-concept formation, status achievement, and adequate social relations. Physical changes need to be integrated into evolving body image (strong, competent, powerful, or weak and helpless).	Growth and changes may produce distorted view of self-overemphasis on defects with compensations; inflated ideas of body ability, beauty, perfection; preoccupation with body appearance or body processes, women more likely than men to see body fatter than it is; egocentrism.
Early Adulthood	Learns to accept own body without undue preoccupation with its functions or control of these functions. Stability of body image.
Middle age	New challenges due to differential rates of aging in various body parts. Body not functioning as well, unresolved fears, misconceptions, and experiences in relation to body image persist and become recognized.	Less dependable, less likable body-regression to adolescent behavior and dress due to denial of aging, defeat, depression, self-pity, egocentrism due to fear of loss of sexual identity, withdrawal to early old age. Women more likely to judge themselves uglier than do men or younger and older women.
Old age	Accelerated physical decline with influence on selfconcept and lifestyle. Can accept self and personality as a whole; continued emphasis on physical self, with increased emphasis on inner, emotional self.	Ill health-fear of invalidism, hypochondriasis. Denial related to feelings of threatened incapacity and fear of declining functions. Despair over loss of beauty, strength, and youthfulness, with self-disgust about body projection of criticism onto others. Regression. Isolation (separation of affect and thought) leads to less intense response to death, disease, aging. Compartmentalization (focus on one thing at a time) causes narrowing of consciousness, resistance, rigidity, repetitiveness. Resurgence of egocentrism.