Acta Psychopathologica Open Access

Keywords

Self; Body image; Attachment; Family environment; Parenting

Introduction

Body image is the subjective representation of one’s own body and incorporates perceptual, cognitive, affective and behavioral components [1].

Body dissatisfaction is the negative subjective evaluation of one’s own physical appearance (comprising shape, weight, specific body parts); it can be associated to an alteration in body perception but it is mainly in the domain of the cognitive/affective component of the construct of body image. Body dissatisfaction is recognized to be a risk and perpetuating factor for eating disorders and it is linked to unhealthy behaviors, poor self-esteem, and depression [2]. More attention is paid in today psychiatry and psychoanalysis to the inextricable connection of the mind to the body (in Freud’s words: “The ego is first and foremost a bodily ego” and to the fact that the evaluation of the body is closely related to the evaluation or devaluation of the self in childhood, adolescence and adulthood [3,4].

The relationships within the family are important contributors for the development of the self, especially at an early age, and part of this contribution can be evidenced in the role of familial dynamics in the development of body image satisfaction and dissatisfaction.

Attachment assessment is now a widely used instrument and it has been providing the theoretical framework to explore how early interaction within the family can contribute in developing issues with the body image.

Methods and Methodological Issues

The scope of this paper is to review the recent literature on family functioning and body image. It is not a comprehensive analysis of all the papers published on the theme but aims at providing a general view of the subject, with more attention to attachment research and longitudinal studies. To perform the review they were considered the database Pubmed and the journal Body Image. The authors searched for articles published between 2000 and 2017 with a combination of the terms “body image”, “body dissatisfaction”, “family”, “parents”, “attachment” and similar, additional papers were obtained from the references. Studies on this issue are often cross-sectional in nature and do not allow inferences on causality. Longitudinal studies are always invoked for the exploration of the temporal link between the factors in play but are more difficult to put in place.

The great majority of studies use self-report measures, which can be associated to biases like the differential recollection based on the current status (“effort after meaning bias”) or the underreport of stigmatized behaviors [5,6]. For example it might be possible that when body dissatisfaction is already present it leads to the recollection of body-related comments and negative interactions with parents more often than when it is not. For clinical populations in the first stages of treatment self-reported measures can manifest willingness to change in treatment rather than description of current status. Questionnaires developed for females might be responsible for part of the sex differences evidenced in the literature [7]. Clinical as well as nonclinical or subclinical populations need to be studied since the determination of body image dissatisfaction may differ between them instead of being simply more acute in patients that arrive to clinical attention. Direct and indirect pathways of influence are explored, as well potential differences in the pathways for paternal and maternal figures. While body image dissatisfaction has been long considered a problem mainly related to adolescence there are now more evidences for its origin in childhood.

Positive body image, instead of simply being the opposite of negative body image, is emerging as construct of its own and there are now more studies that search for its determinants [8]. Few studies today explore treatment and prevention specifically targeted for body image issues.

Results and Discussion

Research on attachment issues

Research on body image based on the biopsychosocial model identified three sources of environmental stressors: parents, peers and media. These three are incorporated in the so called tripartite model which also considers their interactions and includes social comparison and internalization of cultural norms as mediators [9-11]. Various studies highlight the role of the new social media in these processes [12,13]. So in addition to considering direct parental influences on body image it is also useful to consider family dynamics’ impact on media and peer influences leading or not to body image issues. The media are known to be responsible for the spread of the thin ideal in western societies. However in front of almost ubiquitous stressors not every youngster incorporate them into a self-concept, so factors influencing this differential internalization need to be explored.

Attachment has proved as a reliable and quite stable indicator of early interactions’ impact on the ability of forming secure bonds throughout a person’s life. Attachment theories was developed by Bowlby moving from animal studies and underlie the relevance of very early relationships with caregivers for the internalization of working models about the self and others which are generally maintained in adult life [14]. Ainsworth further developed Bowlby’s theory by using the famous experimental setting known as the “Strange Situation” and later through longitudinal observation and interview to children and parents to characterize the categories of attachment [15,16]. Individuals who are identified as securely attached are characterized by trust in others and positive view of self and do not fear intimacy or separation. Insecure attachment on the other hand is subtyped in avoidant or anxious based on discomfort in one of these two areas, with anxiously attached individuals having trouble in handling separation and avoidant being uncomfortable with intimacy [17,18]. Anxiously attached individuals are thought to have a negative view of self and high need of approval from others, while individuals with attachment avoidance hold a positive view of the self and negative view of others [19].

Attachment insecurity has been recognized in a variety of psychiatric disorders [20-22]. In eating disorders research there were some contrasting evidences about the association of attachment subtype with specific diagnosis, with some authors suggesting a link between attachment avoidance and anorexia nervosa and between attachment anxiety with bulimia nervosa. Others evidences support that instead of such an association it is better to speak about a link between the insecurity of attachment with the degree of symptom severity [23,24].

Attachment patterns arise from the interaction of the children temperament with parental attitudes.

The relationships between style of parenting and psychological outcomes in the children has been studied particularly in the work of Baumrind that led to the initial identification of three parenting styles (authoritative, authoritarian and permissive) to which the neglectful style was later added. These styles can be distinguished through differences in the dimensions of responsiveness and demandingness [25,26]. In recent years the interest in studying the relationship between attachment and body image has grown. Cheng and Mallinckrodt developed a model to explore parental care and body dissatisfaction [27]. They recruited a sample of healthy college women and tested how the quality of parental bonds and the security of the attachment could protect from the internalization of images from the media. They found that media internalization mediated the effect of anxious attachment on body dissatisfaction. They evidenced differing paths from fathers and mothers (i.e., direct relationship between memories of warm and accepting maternal but not paternal care and body image satisfaction). Mother’s and father’s care were linked to attachment anxiety which was connected to body dissatisfaction through media internalization.

Also Hardit and Hannum examined the moderation of environmental messages on the body satisfaction of nonclinical female individuals, with a sample of undergraduate women [28]. The anxiety about relationships in girls with anxious attachment was linked to a greater preoccupation about their bodies. The authors suggested that the concept of body shape and size as a physical mean for self-devaluation would confer greater vulnerability to external influences

Eggert and collaborators showed that in healthy population attachment insecurity and body dissatisfaction could be both explained by considering personality traits [29]. Abbate-Daga et al. explored a clinical group and came to different conclusions. In a sample of eating disorders patients they evidenced the characteristic personality traits of this population using the TCI (high Harm Avoidance, high Reward Dependence, low Self Directedness and Cooperativity) [30]. It was however the high attachment insecurity (in particular the need for approval scale) that invariably predicted body dissatisfaction after checking for personality and confounding variables together, leading to the conclusion that, as far as influences on body image are concerned, attachment is not a variation in personality but an independent construct.

Again considering a clinical population, Grenon et al. applied the previously cited model of Cheng and Mallinkcrodt on a sample of girls with eating disorders [31]. Different pathways for the patient’s recollection of mothers and fathers care were evidenced. Poorer emotional bond with fathers was linked to body dissatisfaction through media internalization, while mother’s care seemed directly related to girl’s body satisfaction. As other authors before they proposed a critical role for attachment anxiety in developing body dissatisfaction, due to high need of approval and negative view of self.

Role modeling, critics and comments, gender

Before the focus on attachment, the research on family and body image has been concentrated on two main modalities of influence by parents, namely parental modeling and parental attitudes, and there is still growing research in this direction [4,32,33]. The first of these modalities refers to the influence, somewhat implicit; that parents would have on the offspring by transmitting behavior and beliefs they hold for themselves after which those of the offspring would be modeled. In this sense parent’s dieting behavior and body image dissatisfaction would contribute to daughters’ and sons’ own unhealthy habits and negative beliefs about their bodies [34]. However also a positive modeling effect is possible (for example the regularity of the family meals has been shown to be related to less disordered eating in the offspring) [35].

The other modality regards the explicit comments made by parents concerning eating habits and body shape and size. There is a strong correlation between the recollection of critics and teasing and the presence of body dissatisfaction [33]. However while mainly negative comments directed to the offspring have been investigated, there is also evidence for the effect of comments directed at others (for example TV characters) and for comments intended to be positive [36]. In fact the encouragement to control weight is a strong predictor of body dissatisfaction [37]. Creating a familial environment in which the attention is set on certain standard in relation to body and eating could facilitate the incorporation of the cultural messages highlighted before in the tripartite model.

Both the modeling and the attitude modality receive support from the literature [38].

Regarding gender differences (which are studied in relation to the offspring as well as for the gender of parents) some studies evidence a more observable effect of parental influence on girl’s body image and strategies to control weight and body shape, but as stated before this could partly depend on the measure used [39,40]. Body ideals are gender specific, and for example the drive to muscularity to which boys are subjected has to be investigated differently [41,42].

Longitudinal studies and age differences

Adolescence is thought to be a period in which the bodily and mental changes that occur with puberty can facilitate the onset of body image disturbances, so most research has focused on this critical phase. However there is now evidence that body dissatisfaction, intended as the desire for a different body size and shape, and the preference for thin bodies can emerge as soon as 5 years of age, especially in girls [43-46]. As underlined before not all the studies use instruments which are designed for children, so further research is needed, as well for the modality by which parents can promote or buffer the early incorporation of these beliefs in the forming self [47,48].

Independently of the age of onset of body image disturbances, body satisfaction and dissatisfaction could be differentially influenced based on the life phase [49,50]. Parents could be more relevant in childhood and early adolescence, after which peers would exert greater pressure and in adult age other attachment figures could be more relevant than both.

Along this line, well conducted longitudinal studies give a picture of these different contributions. The group of Presnell et al. found mixed results in two longitudinal studies, with the first not supporting longitudinal evidence of parental support on body dissatisfaction and the second evidencing support from parents as a predictor of body dissatisfaction for boys and girls [51,52].

Boutelle et al. studied the connectedness, the sense of closeness and belonging within the family, in relation to body image longitudinally [53,54]. In the family viewed as a system every member influences the other and is in turn influenced by him/her. Both authors’ studies found that the parent-child connectedness predicted body satisfaction years later. In turn body satisfaction was a predictor of family connectedness.

Herfert and Warschburger found that in a year period encouraging parental comment addressed to the control of weight and shape were the strongest predictor of body dissatisfaction [55].

Holsen et al. examined data from a Norwegian sample in the years of adolescence and early adulthood, from the age of 13 to the age of 30, to capture the relationship between early parental interactions and body image development [56]. They confirmed the role of BMI and the gender differences (males having a more positive body image than females) known in the literature but unexpectedly they detected a stable growth in body image satisfaction in adolescence with a stabilization in adult age, which could be not generalizable to other population. Anyway they confirmed that the quality of early interactions with parents, after controlling for BMI, significantly predicted the child’s initial level of body satisfaction. There was a steeper growth in body satisfaction for those who reported worse relationship at the beginning; anyway the quality of relationship with parents seemed to continue to have an effect even at an age when peer interactions were predominant.

Yu analyzed male and female adolescents in South Korea, a country where cultural pressures about unattainable beauty standards are known to be particularly spread. They evidenced that different body image satisfaction trajectories could be related to different antecedents regarding parent-child connectedness, in the sense that girls who reported poorer connectedness with parents had a bigger probability of being in class of high body dissatisfaction at the end of the observation, while high parent-child connectedness emerged as a protective factor [57].

Clinical and preventive interventions

The knowledge of the predictors of body dissatisfaction within the family functioning is useful for both individual and familial treatment as well as for prevention of body image related problems. Being informed of the attachment style can guide the treatment and has a potential influence on its outcome [58,59]. Therefore therapists who treat patients with body image disturbances (and generally the other psychiatric disorderes where attachment is shown to play a significant role) should asses their attachment type with validated measures. The study by Tereno et al. evidenced the influence of attachment on the therapeutic relationship in relation to the therapy outcome [60].

Especially in childhood parents should be aware that warm and supportive relationship can promote body and self-acceptance, and should avoid to create a familial environment in which there is a focus on weight and shape related issues (even in the form of encouragement to change the eating habits). Attachment anxiety has been shown to be particularly relevant for body image dissatisfaction, and when encountered should be targeted since childhood by fostering the development of secure attachment in order to prevent the internalization of negative cultural standards [19].

In this direction also psychoeducational programs should be created for helping parents in the task of resisting the incorporation of the thin ideal or of others unattainable standards in the familial environment. Prevention programs based on the systemic perspective may include all family members and should have a capillary distribution at the population level, knowing that any member of the family can influence the others. An example of a psychoeducational program for parents of young children is the one put in place by Mc Cabe et al.; in their study parents of 3-6 years old children took part in two workshops after which they experienced greater knowledge of the factors influencing their children body image development [61].

Conclusions

Many studies highlight the relationship between family functioning and body image, investigated under the lens of different theoretical approach which put emphasis on its various aspects. The interactions within the family are complex and it is not easy to unravel their contribution to the definition of the body evaluation, especially when they are studied retrospectively. However the works reported in this mini review, among others, lead to define a clear role for early care and implicit and explicit messages about the body in forming body image satisfaction and dissatisfaction. Insecure attachment style, in particular the more studied anxious attachment style, seem to confer greater vulnerability for the negative evaluation of one’s own body according to externally acquired standards. When examined separately, differing pathways for mothers’ and fathers’ influences seem to emerge, e.g. a direct effect of mother’s care on daughters’ body image and an effect of father’s care mediated by the incorporation of cultural standards. The role of siblings is still understudied. Attachment is not a variation in personality and need to be explored separately from it in the clinical assessment. Regarding the recollection of explicit messages those with major effects seems to be not the overt critics but the parental comments of encouragement to engage in activities that would result in body change. The knowledge coming from the longitudinal studies permits to identify the initial quality of interactions within the family, variously assessed, as a predictor of the degree of later body dissatisfaction.

Family represents the critical environment where early psychological development occurs and can therefore influence it. Prevention of body disturbances must pass through education of the parents, encouraging warm and supportive relationships with the offspring that can buffer media influences and contribute to healthy and positive beliefs about the self and the body.

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