Body Image as a correlate of generalized anxiety and depression among South African adolescents

TABLE OF CONTENTS

Sworn Statement

Acknowledgements

Abstract

List of Figures / Tables

1. CHAPTER 1 – ORIENTATION
1.1. Background
1.2. Analysis of the problem
1.2.1. Awareness of the problem
1.2.2. Exploring the problem
1.2.3. Problem Statement
1.3. Aims of Research
1.3.1. General Aims
1.3.2. Specific Aims
1.4. Research Methods
1.5. Demarcation of the study
1.6. Explanation of the concepts
1.7. The Research Programme

2. CHAPTER 2 – LITERATURE REVIEW
2.1. Introduction
2.2. Definition of body image
2.2.1. Causes of body image problems
2.2.2. Triggers
2.2.3. Perpetuating the problem
2.3. Body Dysmorphic Disorder (BDD)
2.3.1. Causes of Body Dysmorphic Disorder
2.3.2. Gender and BDD
2.4. Anxiety
2.4.1. Appearance Anxiety
2.4.2. Signs of adolescent anxiety
2.4.3. Symptoms of anxiety
2.4.4. Chart of anxiety disorders
2.5. Depression
2.5.1. Definition of depression
2.5.2. Prevalence
2.5.3. Myths around adolescent depression
2.5.4. Theory on causes of depression
2.5.5. Symptoms and signs
2.5.6. Causes of depression
2.5.7. Predictive factors
2.5.8. Defenses against depression
2.5.9. Subtypes of depression
2.5.9.1. Dysthymia
2.5.9.2. Bipolar Disorder
2.6. Suicide
2.6.1. Prevalence
2.6.2. Reasons for suicide
2.6.3. Myths around adolescent suicide
2.6.4. Warning signs
2.6.5. Suicide ideation
2.6.6. Sexuality and suicide
2.7. Conclusion

3. CHAPTER 3 – RESEARCH DESIGN AND METHODOLOGY
3.1. Introduction
3.2. Hypotheses
3.3. Selection of the sample
3.4. Screening Tools
3.4.1. Body Image Questions
3.4.2. Choate Depression Inventory for Children
3.4.3. Hospital Anxiety and Depression scale
3.5. Coding of data
3.6. Procedure
3.7. Processing of the results
3.8. Testing the hypotheses
3.9. Sources of error

4. CHAPTER 4 – PRESENTATION OF RESULTS AND DISCUSSION
4.1. Introduction
4.2. Demographic results
4.3. Body Image Dissatisfaction
4.4. Choate Depression Inventory for Children
4.5. Hospital Anxiety and Depression Questionnaire
4.6. Further analysis

5. CHAPTER 5 – CONCLUSIONS
5.1. Introduction
5.2. Summary of results from the empirical study
5.3. Evaluation of Hypotheses
5.4. Research implications
5.4.1. Educational implications
5.4.2. The role of the educator
5.4.3. Guidelines for improving adolescent emotional well-being
5.4.4. Parental implications
5.5. Recommendations
5.6. Conclusion

References

Appendices:
Appendix A: Administrators Instructions (Guidelines)
Appendix B: Questionnaire
- English version
- Afrikaans version
Appendix C: Raw Data

LIST OF FIGURES / TABLES

Figure 1: Interrelationship of the ‘Three A’s of Happiness’

Figure 2: Historical influences on Body Image development

Figure 3: Beck’s Cognitive Triad

Figure 4: Cycle of Thoughts and Efforts

Figure 5: Symptoms specific to anxiety and to depression

as well as symptoms shared by both states

Figure 6: Chart of anxiety disorders

Figure 7: Categorized Mood Disorders

Table 1: Screening Tools

Table 2: Questionnaire completion success by School

Table 3: Cross tabulation of School by Grade

Table 4: Cross tabulation of School by BIDLEVEL

Table 5: Cross tabulation of Sex by ANXLEVEL

Table 6: Cross tabulation of Sex by BIDLEVEL

Table 7: Cross tabulation of Sex by DEPLEVEL

Chart 1: Chart of School by Grade

Chart 2: Chart of Sex by ANXLEVEL

Chart 3: Scatterplot of BIDRAW and DEPRAW

Chart 4: Scatterplot of BIDRAW and ANXRAW

Chart 5: Scatterplot of DEPRAW and ANXRAW

SWORN STATEMENT

I hereby state that ‘Body Image as a correlate with generalized anxiety and depression in South African adolescents’ is my own work, and, to the best of my knowledge, it does not contain materials previously published or written by other people, nor has its content ever been substantially accepted in exchange for academic grades or university degrees from AIU or other post-secondary institutions, except properly acknowledged within the document.

Signature: ____________________

Name: Gary William Elliott

Date: March 2011

ACKNOWLEDGEMENTS

The long, arduous journey towards this, the end product of much hard work would not have been possible without the help of a number of people:

- Firstly, to both my supervisor and academic advisors, Dr D Mebane-Williams and Lauran Benjamin for their patience, encouragement and astute guidance.

- To Petra, for the translation work on the questionnaire.
- To Louise, for the proofreading and advice regarding grammar and style.
- To Jeanette and Ida, for their assistance in the typing, copying and collating of the numerous questionnaires.
- To Reshmee, for picking up the slack at home, giving me support and allowing me the time to work.
- Finally, to my friends and parents, for their understanding and believing in me to fulfill this dream.

March 2011

ABSTRACT

The main objective of this study was to conduct an empirical investigation to gather information from adolescents in the Pretoria area as to their level of body image dissatisfaction, anxiety and depression. This information was used to identify whether correlations exist between these three variables for South African youth.

A literature study was conducted and the following hypotheses were developed for study:

I. Adolescent females report higher (more severe) levels of body image dissatisfaction than males.
II. Depression rates among South African adolescents have a female-to-male ratio of 2:1.
III. Depression prevalence rates among South African adolescents are lower than their American counterparts.
IV. Adolescent females display higher levels of anxiety than their male counterparts.
V. A significant positive correlation exists between levels of body image dissatisfaction and levels of depression.
VI. A significant positive correlation exists between levels of body image dissatisfaction and feelings of anxiety.
VII. There is a significant positive correlation between levels of depression and anxiety in South African adolescents.

The gathering of quantitative data took the form of a structured questionnaire comprising four distinct sections: demographic information, the Body Image Satisfaction scale, the Choate Depression Inventory for Children (CDIC), and the Hospital Anxiety and Depression (HAD) scale. The questionnaire was administered to Grade 8-12 learners (aged 13-19 years old) to three different high school in the area, both independent and public schools. The sample group was randomly selected and yielded 350 completed questionnaires. Data was entered into the Moon Stats statistical programme for analysis; affording the opportunity to generate univariate and bivariate statistics together with the calculation of Pearson product moment correlations.

Analysis of the data yielded the following results:

‘Moderate’ levels of body image dissatisfaction was recorded by 17,7% of the sample group; 66,1% of this were female respondents. ‘Severe’ levels were recorded by only 1,1% of the sample group, all of which were females. ‘Moderate to Severe’ levels were recorded in 6% of the male population and 12,86% of the female population.

‘Moderate to Severe’ levels of depression were reported by 20% of the sample group. Males constituted 9% of this portion and females the remaining 11%. The ratio of prevalence rates for female to male was calculated at 1,2:1. These percentages for males fall slightly below and for females significantly below the American percentages of 10% and 40% respectively.

Female respondents recorded higher levels of anxiety. 42,9% of the population recorded ‘moderate to severe’ levels of anxiety, 22,7% of this component was female. It was interesting to note that 50,4% of the ‘moderate’ category was male respondents.

The Pearson product moment correlation was calculated from the raw data for Body Image Dissatisfaction and Depression. The Pearson ‘r’ was calculated at r(x,y)=0,55 which suggests a strong positive correlation, statistically significant at the 1% level.

Body Image Dissatisfaction and Anxiety raw data yielded a Pearson ‘r’ value r(x,y)=0,46, suggesting a moderately strong correlation.

The Pearson product moment correlation was calculated from the raw data for Anxiety and Depression and yielded r(x,y)=0,63, suggesting a strong positive correlation, statistically significant at the 1% level.

Educational implications of the findings are discussed and guidelines are given for parents and educators.

CHAPTER 1 – ORIENTATION

1.1 Background

Psychologists have used the term ‘body image’ to describe our internalized sense of what we look like. This can be viewed as a ‘mental’ representation of our appearance; we assess our external appearance against this mental ‘picture’ of ourselves. Adolescence is the period when the appearance changes dramatically in a relatively short period of time as puberty is reached. The body image may be studied in terms of what we look like as perceived by others, what we actually look like, and our own perception of what we think others see (Veale, Willson & Clarke, 2009).

In Cash (2008) it is suggested that our ‘body image’ is a personal relationship with our body that encompasses our beliefs, thoughts, and feelings about our body and the resulting actions from this perception. The conclusions that form from the internalized image of the body strongly affect the level of satisfaction with the body and ultimately the self-esteem and psychological well-being of the adolescent (Berk, 2000). As much as a third of our self-esteem is directly related to a positive or negative perception of our body image. As such, the body’s physical appearance is an important determinant of peer acceptance.

Puberty is an unhappy period for many children and their level of happiness is dependent on three components; acceptance, affection and achievement as illustrated in Figure 1 (Hurlock, 1987). Acceptance refers to acceptance by others and acceptance of the self; a poor body image will impact extensively on the child’s self-acceptance and potentially on the level of acceptance they perceive from others. This is inextricably linked to feelings of affection; the greater the level of acceptance by others, the greater the perception of affection from others. In order to receive affection from others, the child first needs to express affection towards those around him; this is tremendously difficult for a child with a poor body-image and thus there is a breakdown in the triad of components leading towards happiness.

Most people have a relatively good match between what they think they look like (subjective appearance) and how they appear to others (objective appearance) but distorted thought patterns manifest as a crucial aspect of having body image difficulties. In Bearman & Stice (2008) it is noted that body dissatisfaction can be a potent predictor of depression, above and beyond other predictive factors or risk factors. In addition, the risk for the onset of major depression increases dramatically during adolescence (Hankin & Abramson, 2001). Few researchers have considered the impact of attractiveness on peer relationships during adolescence, particularly that of an adolescent's own subjective evaluation of his body image (Davison & McCabe, 2006). However, some studies have indicated a relationship between body image concerns and symptoms of depression or anxiety among adolescents (Kostanski & Gullone, 1998).

Figure 1: Interrelationship of the ‘Three A’s of Happiness’

illustration not visible in this excerpt

In her article Childhood Depression, Linda Trump suggests that there are a growing number of children in South Africa who are unhappy and even depressed. The sad fact is that there are no South African statistics around childhood depression (Dr Brendan Belsham). We are dependent on statistics for depression on other first-world countries, yet Tomlinson, Grimsrud, Stein, Williams & Myer (2009) suggest that South Africa has a lower rate of depression than America, but a higher prevalence than Nigeria. It is a concern for me that we have adequate statistics on suicides and rates of attempts and completions of suicide among South African youth, but nothing relative to depression. There is very little research on adolescent depression within the South African context and there are no available statistics on the prevalence of body image dissatisfaction or depression.

This study will focus on determining the prevalence and levels of body image dissatisfaction, in conjunction with levels of generalized anxiety and depression among South African adolescents in the Pretoria region of Gauteng. The aim is to begin to gather statistical information on the South African prevalence of these components and determine whether a correlation exists between the level of body image satisfaction and feelings of depression and anxiety.

1.2 Analysis of the problem

This section deals with becoming aware of the problem. A preliminary literature study is done to explore the problem and finally a problem statement is formulated.

1.2.1 Awareness of the problem

In the past, body-image dissatisfaction was thought of as a women’s problem. Males were just not expected to have body-image problems; naturally, men with these problems were reluctant to reveal their preoccupation with their body image. In recent years our culture has helped increase the prevalence of body-image dissatisfaction (Claiborn & Pedrick, 2002).

Our society’s view of an attractive female is thin and long legged and a good-looking male as tall, broad shouldered and muscular. The female societal ‘ideal’ is a girlish shape that favours the girl that reaches puberty later than the norm. The male ‘ideal’ is a more masculine shape that favours the boy that reaches puberty earlier than the norm (Berk, 2000). Adolescence, defined as the period of development from the onset of puberty to the attainment of physiological and psychological maturity, begins in girls at approximately 11-13 years of age and in boys at around 12-14 years of age. Sexual maturity is reached at around 15-16 years in girls and 16-17 years in boys (Reber & Reber, 2001; Hurlock, 1987).

Adolescents find that the physical appearance is a strong determinant of peer acceptance. Boys who reach the onset of puberty at an earlier age (early maturer) than the norm seem to have advantages over those than reach puberty later (late maturer) than the norm. These advantages are evident in their peers’ perceptions of them being more relaxed independent, self-confident and physically attractive (Brooks-Gunn, 1988). Girls who mature early are observed to have social difficulties; they are perceived as less popular, withdrawn and psychologically stressed (Ge, Conger & Elder, 1996). Girls, more than boys express dissatisfaction with their bodies (Baron & Byrne, 2000).

Levels of body-image satisfaction seem to rely on two factors; (1) how closely the adolescent’s body matches cultural ideals of physical attractiveness, and (2) how well young people ‘fit in’ physically with their age mates. Research in Alsaker (1995) discovered that early maturing girls reported a less positive body image, while early maturing boys reported a positive body image. It was also concluded that adolescents who deviated from society’s standards of physical beauty as a result of pubertal timing were less well accepted by their peers and their physical self-judgements correlated more strongly with their overall self-worth than any other self-esteem factor. It was evident in the study that the preference for attractive over unattractive adolescents translated into differential adult and peer treatment (Berk, 2000).

Depression and a negative body image are often intertwined, depression can cause an adolescent to detest their looks and vice versa, the self-disparaging thoughts of hopelessness and helplessness about their looks can be depressing; in turn their despondency traps them into additional self-criticism, leading to a vicious cycle of despair (Cash, 2008). According to Veale, Willson & Clarke (2009), depression nearly always occurs after the onset of a body image problem. Girls are believed to be twice as likely as boys to show an onset of depression between the ages of 13 and 16 years (Hankin & Abramson, 2001).

Research conducted by Davison & McCabe (2006) suggests that although there are more negative evaluations of body image among girls than boys, the connection to self-esteem was found to be similar for boys and girls. The work of Siegal (2002) agrees with this conclusion and purports that body dissatisfaction is a predictor of depressive symptoms for boys as well as girls.

Anxiety often develops after a period of frequent and intense worry that undermines a child’s self-confidence and predisposes them to generalized feelings of inadequacy (Hurlock, 1987). Anxiety is found to become more intense during puberty and is expressed as depression, nervousness, irritability and mood swings. The anxious child has a tendency to be unhappy and feel insecure in social situations. Approximately 8% of teens experience anxiety or depression and affects 13% of children and adolescents during any given six-month period. The Mood Disorders Society of Canada places this percentage at 12% (McIntosh & Livingston, 2008). In Seedat (2010), it is suggested that depression and anxiety disorders frequently co-exist and the presence of an anxiety disorder is the single greatest risk factor for the development of depression.

I would like to suggest that there is a distinct link between poor body-image, or body-image dissatisfaction and the sensation of anxiety and feelings of depression; that is heightened during the course of puberty for both males and females. The adolescent years are filled with personalized evaluations of body-image which, if negative, have the potential to translate into anxiety around the appearance and depression.

1.2.2 Exploring the problem

Adolescence is a time of acute stress and parents would seem to be a natural source of support and understanding during this period. Peers might serve this function to some extent, but it seems likely that certain types of doubts and anxieties cannot be shared with friends, given the volatile nature of peer associations during this period of social sorting and identity formation (Robertson & Simons, 1989).

We are working with a generation of adolescents that often arrive home to empty homes, with both parents working. It is alarming that studies indicate that nearly a third of Johannesburg’s children and nearly half of Soweto’s children fall into this category (Van Zyl Slabbert, Malan, Marais, Olivier & Riordan, 1994). Unsupervised adolescents are more prone to substance abuse, risk-taking behaviour, depression and low self-esteem (Richardson, Radziszewska, Dent & Flay, 1993).

South African teenagers are subject to more stress than teenagers of previous generations were. The University of South Africa (UNISA) substance abuse research project of 2000 indicates that 14% of scholars find ‘sexual issues’ as the one thing which challenges them the most and another 15% mentioned ‘doing well at school’ as the most important challenge facing them (Ovens, 2001). The teenagers’ feelings of social adequacy depends, in part, on how they think their appearance is perceived by peers and how that will affect their chances in the dating game (Cash, 2008).

Early identification and aggressive treatment of depression is a useful first step in addressing the clinical problem of suicide. Roy (in Jacobs, 1999), found that only 29% of the suicide victims in his study who were depressed were receiving adequate antidepressant treatment at the time of the suicide. According to the World Health Organisation, a suicide occurs every 40 seconds and an attempt is made every 3 seconds. Risk factors for suicide among the young include the presence of depression and in South Africa, 60% of people who commit suicide are depressed. In South Africa, the average suicide rate is 17,2 per 100 000, or 8% of all deaths and the suicide rate for children aged 10-14 years old has more than doubled over the last fifteen years (http://www.sadag.co.za). Teenage suicide is becoming more common every year in South Arica, with 9% of all teen deaths being a result of suicide. It is important to remember that most suicidal people are depressed. The fastest growing age group for adolescent suicides is females aged 15-19 years of age. This would suggest that levels of depression are exceedingly high in this age group and this could be attributed to, in part, by poor body-image, as will be suggested during the course of this study.

An exploration of the treatment options available to the depressed adolescent reveals that in general the major types of psychotherapy fall into four broad categories (Hirschfield and Shea in Sue, Sue & Sue, 1997).

- Those that focus on helping the depressed individual gain an understanding and awareness of the unconscious forces and conflicts, which result in depressed mood and behaviour. These approaches are best described as insight-oriented therapy.
- Those which directly target changing ‘depressed’ behaviour by changing the consequences which are believed to strengthen and weaken behaviour. These methods fall under the heading of behaviour therapy or behaviour modification.
- Those which stress changing maladaptive ways of thinking as a means of changing resulting emotions and behaviour. This type of therapy is called cognitive therapy.
- Those which emphasize improving the depressed individual’s interpersonal skills and his relationships with others. This category includes interpersonal psychotherapy and family therapy (Ingersoll, 1996).

These methods of treatment have a number of drawbacks for the depressed adolescent, as discussed below:

Insight Oriented Therapy – this is usually a lengthy, expensive process, since therapy sessions are scheduled weekly for periods of time, which can extend for years. With this approach, parents often complain they are ‘out of the loop’ and have no idea what is going on with their adolescent’s therapy, since the bulk of the work takes place between the child and the therapist. Adolescents may find the hard work of therapy tedious and not particularly enjoyable. Certainly if this approach is to be successful, it requires that the young person make a commitment to a lot of hard – sometimes painful – work for a fairly long period of time. While there are some very bright, verbal young people who can follow through on such a commitment, many adolescents find the experience uncomfortable, incomprehensible, and therefore of little help (Ingersoll, 1996).

Behaviour Therapy – there is evidence to show that behavioural methods can be very helpful for specific problems associated with depression, such as social withdrawal, school refusal and poor school performance. However the scope of behaviour therapy is limited: behavioural techniques alone cannot offer a comprehensive treatment programme for depression (Sue, Sue & Sue, 1997). Behavioural techniques such as modeling, rehearsal, self-monitoring and rearranging consequences are important components of other forms of treatment.

Cognitive-Behavioural Therapy – researchers who have studies the thought patterns and beliefs of depressed individuals tell us that negative bias and cognitive distortions accompany depressive illness in both adults and children. Cognitive therapy is designed to help depressed adolescents identify and alter these maladaptive ways of thinking, including cognitive restructuring, attribution training, self-control training and adjunctive techniques such as social skills training (Beck, 1991). The brevity of treatment as well as the structured, directive approach is likely to appeal to adolescents (Sue, Sue & Sue, 1997; Ingersoll, 1996). It is important to note that cognitive therapy has not been verified as an effective treatment for suicidal youngsters or those with co-existing problems such as conduct disorder, substance abuse, personality disorders or learning disabilities (Ingersoll, 1996). Since many depressed adolescents have one or more co-existing conditions, the number of adolescents who might benefit from cognitive treatment might be somewhat smaller than would appear. Most studies on cognitive therapy for adolescents have been concerned with group treatments. Group therapy is considered a particularly useful format for adolescents, but in practice it can be difficult to set up groups of similarly depressed adolescents at any one time (Bednar & Kaul, 1994).

Interpersonal Therapy – a short-term treatment for depression that targets the client’s interpersonal relationships and that uses strategies found in psychodynamic, cognitive-behavioural and other forms of therapy (Sue, Sue & Sue, 1997). Treatment is aimed at correcting these disturbances by improving communication among all family members, teaching problem solving skills, and helping parents re-establish their positions as authority figures in the household. In restoring equilibrium to the dysfunctional family it is assumed that the depressed adolescent will gradually improve as family functioning improves (Ingersoll, 1996).

Antidepressant Medications – antidepressant medications are described as ‘mood regulators’ since they seem to restore normal functioning by correcting malfunctions in the chemical messenger system of the brain. A number of antidepressants work in different and distinct ways to correct neurochemical problems in the brain.

Tricyclic antidepressants are often helpful in treating depressed adolescents but there are a number of disturbing side effects. Adolescent may find these side effects so unpleasant that they discontinue use of the prescribed medication. Tricyclics are also extremely dangerous when taken in overdose, which means they should certainly be locked away from potentially suicidal adolescents (Sue, Sue & Sue, 1997 & MIMS, 1998).

Monoamine Oxidase Inhibitors (MAOIs) are particularly helpful with people who suffer from so-called atypical depression. That is depressive episodes characterized by excessive eating, sleeping, anxiety deterioration in mood and energy across the course of the day, and oversensitivity to perceived slights and rejections (Ingersoll, 1996). A major drawback is that patients who take them must scrupulously avoid foods rich in tyramine, such as aged cheese, processed meats, wine and beer. Adolescents are renown for succumbing to the peer pressure to imbibe alcohol and ‘junk foods’, the risk that MAOIs pose for adolescents is pronounced.

Selective Serotonin Re-Uptake Inhibitors (SSRIs) – are the newest drugs on the market to treat depression. They have few serious, long-term side effects. Research has shown that this medication is both safe and effective for the treatment of mood disorders in children and adolescents (MIMS, 1998).

Successful treatment of adolescent depression rests on:

- The early and accurate diagnosis of depressive symptoms;
- An understanding of the specific aetiology of the adolescent’s depression;
- A broader understanding of the epidemiology of adolescent depression within the adolescent’s specific context;
- An up-to-date understanding of the world for the adolescent in the new millennium.

1.2.3 Problem Statement

In the South African context our understanding of the contributing factors of adolescent depression is rather limited. Psychosocial and social risk factors for depression and early warning signs of adolescent depression remain elusive without adequate understanding of these factors. Our statistics on the prevalence of both depression and body-image dissatisfaction among South African adolescents is extremely limited. Suggesting research into the prevalence of body-image dissatisfaction and depression among our youth and a correlation between the adolescent’s body-image and levels of depression may result in a greater awareness among adolescents, educators, parents and professionals to this potential risk factor.

Is it possible to suggest that insufficient understanding of the connection between their self-image (self-esteem) and a propensity for the development of depression could be resulting in a greater number of potential, adolescent suicide attempts?

It would appear that there is a valid need for studies, in the South African context in particular, on adolescent body-image as a potential risk factor for depression. Our parents, educators and professionals would benefit from greater insight into this topic; development of this research could result in a better awareness of the adolescent’s appearance anxiety and a stronger set of signs and symptoms as evidence for emotional and social distress.

1.3 Aims of Research

This section concerns the aims of the research and deals with the general and specific aims for the research undertaken.

1.3.1 General Aims

The objectives for this research are based on gathering information from Grade 8-12 learners from the province of Gauteng in South Africa covering the areas of body image, anxiety and depression. The general aim is to identify a correlation between body image and anxiety and depression among adolescents in the South African context.

The specific objectives for this research are outlined in question format below:

- Do adolescent females express higher levels of body image dissatisfaction than their male counterparts?
- Is there a ratio of 2:1 for female-to-male rates of depression in South African adolescents?
- Is the prevalence of depression among South African adolescents really lower than our American counterparts (at 10% for males and 40% for females)?
- Do the females in this study display greater levels of anxiety than males?
- Is there a correlation between body image satisfaction and levels of depression?
- Does a correlation exist between body image satisfaction and feelings of anxiety?
- Is there a correlation between levels of depression and anxiety in adolescents?

1.3.2 Specific Aims

The specific aim of this study was to use the Body Image Questionnaire, the Choate Depression Inventory for Children (CDIC) and the Hospital Anxiety and Depression (HAD) scale, as screening tools to investigate the correlation between body-image, appearance anxiety and depression among South African adolescents.

1.4 Research Methods

This study was comprised of two components: namely the literature study and the empirical investigation. The literature study provided information with regard to body-image perception, generalized anxiety, and appearance anxiety in particular and depression in adolescents, with particular focus on adolescents in South Africa.

The empirical investigation of the study attempted to determine the epidemiology of adolescent depressive symptoms and the influence of body-image on these symptoms. This was achieved by means of a questionnaire which was completed by the adolescents. A pilot study was conducted with a smaller sample group of Grade 8 adolescents and feedback from this process denoted any confusion in the application or wording of the questionnaire. As a result of this feedback the questionnaire was refined prior to mass distribution. A sample of Grade 8 – 12 adolescents in the city of Pretoria in the Gauteng Province was selected for the research study.

1.5 Demarcation of the study

Depression is a medical condition, and as such requires a clinical diagnosis. This posed problems for this research; as such it is essential to emphasize that this study is empirical in nature, relying on the completion of a questionnaire, which assessed body-image, generalized anxiety and identification of depressive symptoms. The screening tools used in this research are not diagnostic in nature.

This study also focused on a sample of adolescents from Secondary Schools in the Pretoria urban area. The results of this study attempt to reflect the generalized urban population of South African adolescents. Pretoria was selected for practical reasons, but we can consider it to be representative of any urban area in South Africa.

1.6 Explanation of the concepts

This section serves to define some of the concepts that are relevant to this research.

- Adolescence – adolescence is defined as the period from puberty (12 or 13 years) into the early twenties. During this period, which Erikson called Identity versus Role Diffusion, the child has to integrate all of the tasks from the previous four stages into a coherent identity, and prepare to face the world as an independent adult. In addition to dealing with the changes in his or her body brought on by the onset of puberty, the adolescent must compare and integrate how others see him or her and how he or she sees himself/herself. The adolescent must also adjust to his or her budding sexuality (Erikson, 1968).

- Anxiety – most generally, a vague, unpleasant emotional state with qualities of apprehension, dread, distress and uneasiness. Anxiety is frequently distinguished from fear by its being often (usually say some, always insist others) objectless, whereas fear assumes a specific feared object, person or event (Reber & Reber, 2001).
- Appearance Anxiety – apprehension or worry about whether one’s physical appearance is adequate and about the way one’s appearance is evaluated by other people (Dion, Dion & Keelan, 1990).
- Body Dysmorphic Disorder – a somatoform disorder characterized by preoccupation with an imagined defect in appearance (Reber & Reber, 2001).
- Body Image – or ‘body concept’ is the subjective image one has of one’s own body, specifically with respect to evaluative judgements about how one is perceived by others and how well one is adjusted to these perceptions. Some use the term only in relation to physical appearance (as is the case in this research), others include judgements concerning body functions, movement, coordination, etc. (Reber & Reber, 2001).
- Depression – is defined as a psychological state of despondency, dejection, low spirit, sadness, inactivity, and difficulty in thinking, concentrating and in seeing a situation in perspective. Prolonged depression is a common ultimate cause of suicide and a common emotional experience among adolescents (Van Den Aardweg & Van Den Aardweg, 1993).
- Depressive Symptoms – refers to the changes in the body and the mind which are the signs of the mental state of depression.
- Epidemiology of adolescent depression – refers to the study of the causes, spread and control of the mental state of depression.
- Mood Disorder – a category of disorders characterized by disturbances of mood or emotional tone to the point where excessive and inappropriate depression or elation occurs (Reber & Reber, 2001).
- Peer Relationship – is defined as the relationship with people of approximately the same age and status as oneself.
- Puberty – the period of life in which the sex organs become reproductively functional. Onset in the female is fairly clearly marked by the menarche; in the male it is less obvious, but the growth and pigmentation of underarm hair is often taken as criterial. The end of puberty is difficult to specify and many authors simply select an arbitrary cut-off point based on age (e.g. 14 in females and 15 in males are often used), although it should be recognized that there is considerable variation in age of onset and rate of development, so such an approach is of questionable value (Reber & Reber, 2001).
- Self Esteem – the degree to which one values oneself. Note that although the word esteem carries the connotation of high worth or value, the combined form, self esteem, refers to the full dimension and the degree of self esteem (high or low) is usually specified (Reber & Reber, 2001).
- Somatoform Disorder – a class of mental disorders in which there are clear and present physical symptoms that are suggestive of a somatic disorder but no detectable organic damage or neurophysiological dysfunction that can explain them (Reber & Reber, 2001).
- Suicide – the act of taking one’s life.

1.7 The Research Programme

This research comprises five chapters that are outlined as follows:

Chapter 1:

Chapter 1 includes background information on the problem of poor body image and adolescent depression. It includes information on adolescent statistics in the South African context and how body image perception has the potential to contribute towards adolescent depression. This chapter includes an analysis of the problem, the general aims of the study, a description of the research methods used in the study, a demarcation of the study group and an explanation of some of the key concepts and terms used in this paper.

Chapter 2:

This chapter includes a review of the literature on body image, appearance anxiety, adolescent depression and suicide among adolescents. Definitions, prevalence statistics, causes, symptoms and signs, and treatment methods are included in this chapter.

Chapter 3:

Chapter 3 explores the research design and methods. It includes a discussion of the research problem, the aim of the empirical investigation, the research postulate, research tools utilized in the investigation and the selection of the sample. It outlines the collection of data, changes to screening tools, coding of data and compilation of data. The specific hypotheses are clearly indicated and specific assessment of these hypotheses is outlined.

Chapter 4:

This chapter outlines the results of the Body Image Questionnaire, the Choate Depression Inventory for Children (CDIC) and the Hospital Anxiety and Depression (HAD) scale. These results are analysed and correlated where relevant to the hypotheses.

Chapter 5:

Chapter 5 consists of a discussion of research results, conclusions and evaluations of the hypotheses. The research implications are discussed with reference to parents and educators. Recommendations for future research are outlined and limitations of the study are discussed. General conclusions from the research are summarized in this chapter.

CHAPTER 2 – LITERATURE REVIEW

2.1 Introduction

The body image consists of your personal relationship with your body-encompassing your perceptions, beliefs, thoughts, feelings, and actions that pertain to your physical appearance. The body image forms gradually, beginning in childhood. The life experiences of the child/adolescent will lead them to relate to their bodies in positive and satisfying ways, while other adolescents will perceive their bodies in a negative fashion. The major factors that influence body image development can be divided into two basic categories:

1. The historical influences from the past are the forces that shape how the child views their appearance today.
2. The current influences pertain to the events and experiences in everyday life that determine how the child thinks, feel and react to their appearance.

The basic sense of identity is rooted in the child’s experience of being embodied (Cash, 2008). The historical influences on body image can be sub-divided into four components: cultural forces, interpersonal experiences, physical characteristics and changes, and individual personality traits. Figure 2 represents these four factors as they shape all of our body image attitudes – those perceptions, beliefs, thoughts and feelings. Sadly, these factors do not only determine how satisfied or dissatisfied we are with our appearance, but they also determine how invested we are in our physical appearance for defining who we are and who we want to be (Cash, 2008).

Figure 2: Historical influences on Body Image development.

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Adolescents draw conclusions about their appearance and body satisfaction; this affects their self-esteem and psychological well-being (Usmiani & Daniluk, 1997). Society defines a female as attractive if she is thin, girlish looking and long-legged and a male if he is broad shouldered and muscular. These ideal images are synonymous with late maturing girls and early maturing boys. Alsaker (1995) notes that early maturing girls and late maturing boys have a more negative body image; whereas late maturing girls and early maturing boys have a more positive body image.

Adolescents find that the physical appearance is a strong determinant of peer acceptance. Boys who reach the onset of puberty at an earlier age (early maturer) than the norm seem to have advantages over those than reach puberty later (late maturer) than the norm. These advantages are evident in their peers’ perceptions of them being more relaxed independent, self-confident and physically attractive (Brooks-Gunn, 1988). Girls who mature early are observed to have social difficulties; they are perceived as less popular, withdrawn and psychologically stressed (Ge, Conger & Elder, 1996). Girls, more than boys express dissatisfaction with their bodies (Baron & Byrne, 2000).

Girls whose hips and breasts develop earlier than those of their classmates may feel self-conscious. They don’t appreciate their new shape as a sign of approaching womanhood but can only see themselves as grotesque and fat. Boys whose spurt in height and muscularity is slower than that of their peers may worry privately that their body will never catch up (Cash, 2008). In Cash (1995) it is purported that up to 74% of teenagers with moderate to severe facial acne report it as having a damaging effect on their body image.

The self-esteem is a powerful ally in facing and defeating life’s challenges. Adolescents with a secure sense of self don’t easily fall prey to societal ‘assaults’ on their physical appearance. The adolescent who has a basic sense of inadequacy is eager to find any fault with his own appearance.

2.2 Definition of body image

Body Image – or ‘body concept’ is the subjective image one has of one’s own body, specifically with respect to evaluative judgements about how one is perceived by others and how well one is adjusted to these perceptions. Some use the term only in relation to physical appearance (as is the case in this research), others include judgements concerning body functions, movement, coordination, etc. (Reber & Reber, 2001).

Several components make up a balanced body image: balanced body-image perception (everybody has a perceived body image and an ideal body image- a balanced body-image perception is a realistic body image, similar to the view others have of you), balanced body-image response (every person responds in some was to his/her perceived body-image-a balanced response to your body image is one that allows you to accept your perceptions and limit the distress or interference with your life), balanced ideal body image (the body image you aspire to attain-a balanced ideal body image is one that is realistic or within reach), balanced ideal-body-image response (one that is accepting, realistic and positive), balanced self-image (a balanced self-image is one that includes body, mind and spirit; when you put less emphasis on your body image and more emphasis on who you are, your self-esteem, and your self-image, will improve) (Claiborn & Pedrick, 2002).

A survey in 1972, in which people were asked questions about body-image dissatisfaction, found that 36% of men and 50% of women reported dissatisfaction with their mid-torso. In a 1996 survey, the rate of dissatisfaction was found to have risen to 63% of men and 71% of women. Discontent with the overall appearance went from 15% to 43% in men and 23% to 56% in women (Cash, 1997). Boys are much more likely than girls to desire to be bigger. Boys also have a much larger range of acceptable body types, as some desire to be bigger, others smaller, and others refer to be the same size as they are (Yates, Edman, & Arguete, 2004). Body image dissatisfaction is clearly on the rise, and even though the male-female differences in satisfaction with body image has shown an increase between the pre- 1970s era and the 1990s (Feingold & Mazzella, 1998), it is still commonly believed that adolescent males express very little dissatisfaction with their bodies (Davis, Brewer & Weinstein, 1993).

The nature of the relationship between body image and self-esteem appears to be less clear among adolescent boys. Some studies have indicated a relationship between body image concerns and symptoms of depression or anxiety among adolescents of both genders (Kostanski & Gullone, 1998). Other studies have indicated that only girls with body dissatisfaction are at an increased risk of experiencing symptoms of negative affect (McCabe, Ricciardelli & Banfield, 2001). Girls were considerably more dissatisfied with their bodies than boys and were much more concerned than boys about others’ evaluations of their bodies. Body image may not be related to negative affect, which has been evaluated using measures of depression and anxiety. This circumstance however contrasts with previous research (Kostanski & Gullone, 1998). This study supports the conclusion of Allgood-Merten, Lewinsohn, and Hops (1990) that although body image is an important aspect of self-esteem during adolescence, there is no independent relationship between body image and depressive symptoms (Davison & McCabe, 2006). The focus of this research is clarifying the relationship between body image and depression among adolescents.

2.2.1 Causes of body image problems

I spent the first 14 years of my life convinced that my looks were hideous. I was tall, with big feet and bony knees. I felt quite ugly. I had a big nose, big mouth and those kind of far-apart eyes that looked like I had two fish swimming between my ears. Even today, when people tell me I’m beautiful, I do not believe a word of it… Uma Thurman (July 1998).

This section focuses on the causes of body image problems and what makes a person vulnerable to experiencing them. Usually there are fairly obvious triggers for body image problems or vulnerability. If there is a family history of a mental disorder such as depression or anxiety, genetic inheritance could also be a factor (Veale, Willson & Clarke, 2009).

Possible causes of symptoms of body image problems involve three groups of factors, those that:

- Have made the child vulnerable to developing symptoms (for example, childhood abuse, trauma, genetic inheritance and unknown factors)
- Have triggered the symptoms (such as experiencing acne or being disfigured, or living or working in an environment that places exceptional pressure to ‘look’ a certain way)
- Have helped to maintain the symptoms (for example, the way the child reacts, with particular patterns of thinking and acting)
Vulnerability to a body image problem could be due to three types of factors, which may overlap:
- Physical conditions, including medical, biological and genetic causes
- Personality or psychological traits, and
- Life experiences

Mental health problems can often run in families and disorders such as depression, eating disorders or obsessive-compulsive disorder could predispose a child to an increased risk for body image problems. It is important to remember that a genetic factor does not suggest that a body image problem will definitely develop; in a similar light, it is quite possible for a body image problem to develop without the existence of a genetic risk factor (Veale, Willson & Clarke, 2009).

A child with particular personality traits can be more vulnerable to developing a body image problem. Adolescents who tend to be perfectionist, excessively shy or withdrawn have a greater risk for developing a body image problem if these personality traits are coupled with triggers. It has been suggested that healthy adolescents assess their body image in a more positive light; this has a tendency to result in better relationships with their family members and peers.

Adolescents with a poorer body image appear to have problems with their perception; they tend to perceive their bodies as larger than they are and attach a high degree of importance to their physical appearance. Life experiences that make an adolescent vulnerable to body image problems include emotional neglect, rejection, bullying or sexual abuse, leading to feelings of worthlessness.

In Beck (1985) it is suggested that body image problems are caused, primarily, by negative thought patterns, which he labeled the ‘cognitive triad’. This triad revolves around errors in how we think: about ourselves, our world, and our future. It is cyclical, with a perpetual nature and is reproduced below:

Figure 3: Beck’s Cognitive Triad

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Traumatic experiences such as an accident resulting in scars or skin conditions such as acne or eczema, can result in a lot of attention being focused on the adolescent’s appearance (Veale, Willson & Clarke, 2009).

Our culture values the appearance and numerous images of the idea female or male bombards the adolescent through advertising, movies and television programmes. These ‘images’ of the ideal suggest success, wealth and sexual prowess for the physically attractive individual. It is no wonder that there are increasing numbers of adolescents seeking surgery that enhances their appearance. Feelings of physical inadequacy are also often inadvertently created as a result of peer and familial teasing; this is particularly evident during the physical changes of puberty.

It is important to note that the physical changes accompanying puberty do not necessarily lead to body image problems; professionals suggest that levels of body image problems are connected more to how important the adolescent perceives his appearance and the belief that others will perceive abnormalities in appearance (Cash, 2008).

2.2.2 Triggers

A body image problem often occurs as an understandable response to specific events in a particular context. The triggers for body-image problems are usually long-term factors that chip away at the adolescent’s emotional and psychological well-being over time. The most commonly reported triggers for body image problems are reported in Cash (2008) and include:

- Being teased or bullied about being different, for example your height, weight or physical physique
- Being aware of a change in your appearance such as being found attractive and then developing acne or a skin condition
- Being involved in an accident and developing a scar

2.2.3 Perpetuating the problem

Our perception of our physical appearance impacts on the concept of body image and extensively our self-esteem. A negative view of the physical body, a common occurrence during the physical changes of puberty, causes associations, interpretations of situations and impressions to be negative (Diener, Oishi, & Lucas, 2003). These negative perceptions help to perpetuate the negative feelings and thoughts of the adolescent in the typical Beck’s Cognitive Triad as seen earlier in Figure 3.

Intrusive images are those pictures or impressions that ‘appear’ in the mind particularly when the adolescent is in an anxiety provoking situation. These images have the potential to generate sensations or impressions of how they appear to others around them. Adolescents having body-image problems view their physique from the perspective of an outsider and they firmly believe that the distorted image in their mind is a true reflection of their appearance to others. The perpetuation of the concerns occurs when the adolescent begins to expect others to shun him and seeks out situations that will manifest his fears (Veale, Willson & Clarke, 2009).

If the adolescent is ashamed of their physical appearance, they will think negatively of their appearance. As such, they begin to judge themselves in a ‘negative light’ and send cognitive messages to themselves that they are ugly, or fat, or too stupid. These intrusive thoughts can become overwhelming, which may result in feelings of anxiety and depression in the adolescent. The dissatisfaction with the body becomes all-consuming, resulting in the adolescent beginning to brood over perceived flaws or inadequacies without making active attempts to change these intrusive thoughts.

Body shame usually consists of a mixture of different emotions. These emotions include disgust at one’s appearance, anxiety or depression. The shame can be divided into two aspects; external shame and internal shame. External shame refers to shame pertaining to the physical appearance, believing that those around you perceive you to be ugly or unattractive; this has the potential to manifest in anxiety in public or social situations. Internal shame refers to what the adolescent thinks about himself. Again, this occurs when the adolescent rates themselves negatively; they feel unattractive and try to limit contact with others. External and internal shame may co-exist but can exist individually. This sense of shame is something that is learned over time, as the body image develops, probably originating long before the onset of puberty and the physical changes that accompany this period (Veale, Willson & Clarke, 2009).

These adolescents may be seen to seek frequent reassurance from there peers, they may appear to be obsessed with their body and the perceived flaw in particular. These feelings of inadequacy result in the child withdrawing socially and reducing their social circle; often causing an increase in conflict in the home situation as frustrations are expressed on the family members closest to the adolescent. It is common to see adolescents disguising their perceived flaw using clothing, often wearing clothing much larger than is required for the adolescent; in addition they often avoid eye contact or appear aloof or uninterested in the occurrences around them (Cash, 2008).

Adolescents who complain of persistent, intrusive and horrible thoughts about their appearance may have progressed to the disorder known as Body Dysmorphic Disorder (Barlow & Durand, 2005). In order for a body image problem to be diagnosed as Body Dysmorphic Disorder (BDD), the adolescent’s preoccupation with the perceived flaw must cause significant distress or impairment of functioning (Claiborn & Pedrick, 2002). BDD is reported to occur in 1 to 2% of the general population and is found in 8% of people with depression (Phillips 1996). There is insufficient research to show whether this particular disorder occurs equally in males and females. Body Dysmorphic Disorder is reviewed in the following component of this paper.

2.3 Body Dysmorphic Disorder (BDD)

Body Dysmorphic Disorder (BDD) is ‘a psychiatric illness in which patients become obsessively preoccupied with perceived flaws in their appearance’ (Luciano, 2002: p175). Martin & Costello (2008) view it as a severe dislike and concern about some slight or imagined aspect of their appearance, that causes them significant emotional distress and difficulties. Cash (2008) maintains that sufferers have ‘a grossly distorted view of what they look like’ and Phillips (2005) coins BDD as ‘the disorder of imagined ugliness’ (p5).

Body Dysmorphic Disorder is classified as a somatoform disorder because the primary focus is a psychological preoccupation with a somatic issue (Barlow & Durand, 2005). Thompson (1996) explains that the term that preceded Body Dysmorphic Disorder was ‘dysmorphophobia’ which was used by Morselli in 1886 (Morselli, 1886) which literally meant a ‘fear of ugliness’. In 1903, Janet’s description referred to an ‘obsession with shame of the body’; for decades BDD was thought to represent a ‘psychotic delusional state’ (Barlow & Durand, 2005: p183). The first English language paper on dysmorphophobia was not published until 1970; focusing on the fear of other people’s reactions to the imagined flaw in appearance. BDD gained official status in 1987 when it was first published in the DSM-III-R

In the article ‘Body Dysmorphic Disorder in men, psychiatric treatments are usually effective’, Katharine Phillips notes that BDD is an under-recognized yet relatively common and severe psychiatric disorder. Many doctors…do not recognize the condition as yet and simply see it as low self-esteem’ (Paterson, 2008: p51)

It is important to realize that people who do suffer with BDD usually look ‘normal’, but they are preoccupied with an idea that their appearance is abnormal or defective. The preoccupation causes them severe distress and interferes with their daily functioning. (Phillips, 2009). Barlow & Durand (2005) found that up to 70% of college students reported some level of dissatisfaction with their bodies and up to 28% of these met the criteria for BDD diagnosis.

Thompson (1996) finds that patients often have a rather vague complaint of ‘being ugly, misshapen, or odd looking and cannot locate or specify the nature of the defect. In contrast, others localize their concern exactly to features or blemishes, such as a big nose, crooked mouth, asymmetrical breasts, fleshy thighs, protruding buttocks, small penis, birthmark, hairline, acne, scars, and so forth’ (p150). Yet, it is also quite common for people with BDD to have little or no insight what so ever into the degree of exaggeration of their responses to intrusive thoughts of flawed looks. (Claiborn & Pedrick, 2002). Interestingly the most common area of preoccupation is the hair (63% of patients), followed by the nose and skin at 50% and noteworthy is the fact that most patients have preoccupations with more than one area.

People suffering with Body Dysmorphic Disorder can dislike virtually any area of the body and Phillips (2009) notes that on average people report that they are excessively concerned with an average of five different parts of their body over a period of time. In an attempt to cope with their body concerns they perform a number of behaviours, such as mirror checking, excessive grooming, skin picking and reassurance seeking. Phillips (2009) found that two-thirds of people with skin concerns obsessed about their acne or scarring. One-quarter of men with BDD are preoccupied with their overall body build, referred to as muscle dysmorphia. The specific body areas of concern can be present simultaneously or sequentially. Approximately 30% of people are concerned with one body part-or one set of body parts-over time. Approximately 40% are concerned with one body part and then add new parts as time progresses. The remaining 30% is a little more complex, their concern over a particular body or parts will disappear completely and be replaced with a deficit in another, new area.

The real feelings behind the BDD ‘are of insecurity, self-loathing and inferiority’ (Andersen et al, 2000: p207) These ‘core beliefs’ about the defect lead to what Claiborn & Pedrick (2002) call ‘automatic thoughts’, they are so ingrained in the sufferer that they prevent any positive outcome from actions taken to relieve the pain of the obsessions.

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