Mirror, Mirror, on the Wall, I Cannot Guess my Size at All.
by Dr. Donna Redmayne and Krista Redmayne
True Colors
When we look in the mirror, we don’t see purple skin! We typically see our actual hair, eye and skin color. But we do not necessarily see what is actually there when we look at our bodies.We all have a body image, a mental picture of ourselves and an inner sense of satisfaction or dissatisfaction. For many people, this image is based in reality. However, for some of us, our body image may be extremely distorted. Distorted body image has most commonly been studied in female patients with anorexia or bulimia, but research is now suggesting that even normal-weight women may have a distorted body image.
Experience with a large and varied support group involving people who are both pre- and post-weight loss surgery (WLS) has convinced me that a distorted body image is common for many of us. Little research has been conducted with the obese, or those who have lost immense amounts of weight, regarding body image. Do you think you are seeing your “real self?? Are you surprised when you weigh yourself? This surprise may reflect your inability to estimate your weight. Or, you may “recognize? the number of pounds reflected by the scale, but have a completely inaccurate picture of your body size, because your perception of yourself is distorted. Can you pick up an article of clothing and realistically estimate how it will fit? This distorted body image is not restricted to either end of the weight spectrum. Individuals who have had WLS tell me that they never quite recognized how large they actually became, but they also have trouble accepting the true amount of weight they have lost. They still “feel fat,? at least part of the time, regardless of how many pounds they have shed.
The Truth Hurts
Denial is a way of psychologically avoiding pain. Do any of these phrases seem familiar to you? “I don’t look like I weigh as much as I do?; “I have big bones?; “I don’t need to weigh—my weight can’t have changed much since I weighed last?; “You know, the camera adds 10 pounds?… The hidden message in these statements is a denial of the pain of accepting that we are in a battle with weight, and we are losing. Haven’t we all tried a multitude of diets, all of which produced a loss of weight, only to fail in the long run, when we gained the weight back, plus more. This pattern of yo-yo dieting, and the resulting feelings of failure, produces extreme emotional pain and an overwhelming sense of shame. In an effort to distance ourselves from that pain, we repress the awareness of our true body size. Although we recognize that we are overweight, we often fall short of recognizing the actual extent of our obesity. Many of us will avoid the scale, some even refusing to be weighed by our physician during office visits. We may be able to continue in our denial of our weight if we do not see the actual numbers. We also avoid cameras and our reflection in mirrors or windows in this effort to remain in denial of our size. How many “before? pictures do you have?
Although we are refusing to recognize the extent of our obesity, we are also in extreme distress. We acknowledge that we are “fat?, we just don’t want to know how “fat? we really are. We still suffer from depression, low self-esteem and extreme dissatisfaction with our body image.
Pseudo-Size Me
Some people who have lost a considerable amount of their excess body weight seem to have a similar problem accepting their weight loss, and perceiving the size of their body in the present, particularly when this weight loss has been fairly rapid. Some of us have been “super-sized? for most of our lives and are suddenly at, or approaching, an average weight, maybe for the first time. This requires a huge adjustment in self-perception. We may not recognize ourselves when we unexpectedly see our own reflection. If given the option of choosing a picture, figure, or clothing that represents our body size, many of us will regularly overestimate, thinking that we are larger then we are in reality. Support group members report that they consistently choose a size that is two or more sizes larger than what they currently wear. They also report that one minute they may feel “skinny and sexy,? but the next they don’t feel they have changed at all.
“Sara? emotionally described a follow-up visit to her bariatric surgeon. Although her scale at home had indicated that she had lost over 100 pounds, she wept the entire 80 miles to her surgeons office, absolutely convinced that her scale had “lied? and that when she weighed on her surgeon’s scale she would have failed completely and would still be at her pre-surgical weight of 370 pounds. In her mental picture of herself, she was still at her pre-surgical size.
The Broken Image
How does this distorted body image affect our health and safety? The inability to perceive our actual body size increases our risk of resistance to medical and psychological treatment. If we are in denial, we may resist treatment of our obesity. This may mean that we “ignore? symptoms of obesity related illnesses, putting off treatment for diabetes, hypertension, sleep apnea and other life threatening disorders. Often we may avoid seeking medical treatment, only seeing a physician when our symptoms become so extremely severe that we can no longer ignore them. While denying the consequences of our obesity, we still often suffer from depression, which may produce feelings of helplessness and hopelessness. If we feel nothing can be done, every diet has failed, why try?
We often felt very self-conscious, and worried about “fitting in,? whether it was concern about literally fitting in a theater seat or a restaurant booth or figuratively fitting in at the gym or at a party surrounded by thinner people. We may have chosen social isolation to avoid public judgment and embarrassment. We avoid many other activities that are difficult because of our size, joint pain may preclude movement, and we feel out of place engaging in recreational events. It is only when we become desperate because of physical or social limitations that we will finally yield to medical intervention. For some, this means that they have procrastinated long enough that their co-morbidities have made the risks of surgery even higher than they would have been had they opted for treatment at an earlier stage.
Although most of us do not fit the full criteria for Body Dysmorphic Disorder, (BDD) according to the DSM-IV-TR, we exhibit many of the symptoms. At both our top weight and after weight loss, we are preoccupied with our weight and overall body size. We may be extremely distressed by this preoccupation, sometimes dwelling on our perceived “fatness? for several hours or more per day. Many overcompensate by spending excessive time on grooming, buying and changing clothes, and wearing extremely restrictive foundation garments. Some constantly check their reflection to scrutinize their “defect,? while others avoid mirrors altogether. We constantly compare ourselves with others (Am I bigger/smaller than that person?), and feel that others are constantly judging us, taking special notice of how “fat? we are. Anyone who has had WLS and who suffers from the symptoms of BDD may be at a higher risk for post-surgical anorexia or bulimia. Finding that they are in control of hunger for the first time in their lives, perceiving themselves as still “fat,? sometimes even at goal weight, some have chosen to not eat or to purge, even when they have only eaten small amounts, by vomiting or taking laxatives. “Darla? admitted to her surgeon that 18 months post-surgery she was taking very high doses of laxatives every night because she was so afraid of regaining weight. This is dangerous behavior, and since most of us had WLS to regain our health, we do not want to endanger it because of psychological distortions.
Mending the Break
Ok, so we recognize that we have a problem with reality. Obviously, if someone is having moderate to severe problems with distorted body image, the best thing they can do is get professional counseling. If the problems are mild and you are motivated, see if your bariatric center offers psychological workshops, or professionally facilitated (therapy) support group meetings. If a WLS patient without professional training leads your local support group, you might consider asking a psychologist, psychiatrist or counselor to facilitate a meeting occasionally to address psychological issues, including distorted body image. The professional should be familiar with BDD, eating disorders, and obsessive-compulsive disorders.
The following are some ideas that can be used, either through workshops or support groups, to begin to help make the emotional, cognitive and behavioral changes necessary to be successful in our acceptance of our true selves.
• Research genetics—It helps to understand that your body shape will probably resemble other members of your family. Who do you most resemble in body shape and size? You will probably continue to resemble this person as your weight drops.
• Talk about negative thinking; replace negative “self talk? with positive affirmations—Repeat these affirmations every day. Phrases like, “I approve of myself? and “I feel good and am getting better every day? may feel artificial for us at first, but after time we will begin to accept their truth.
• Think about what situations make you feel fat—Journaling can sometimes help in this effort. After you are aware of these situations, you can choose to avoid them or to find ways to change either the situation or your thinking so that you begin to feel good about yourself in every situation.
• Learn relaxation and meditation exercises—If you are extremely anxious or self-critical, these exercises help to put thoughts and behaviors into the proper perspective.
• Put “before? and “after? pictures adjacent to each other in a prominent place, so that you see the difference regularly—Ultimately you will begin to see the changes you have made. Remember to change the “after? picture as you continue to lose weight!
• If you have a place to draw an outline around your body before your surgery, do so—This can be done on butcher paper, on the garage drywall, or any other place that it is ok to draw on the walls. Then, as you lose weight you can see a life-size depiction of your pre-surgical self.
• Use visual aids—“Steve? had a belt that he wore at his 450+ pound pre-surgical weight. As he lost, he just kept putting new holes in the belt. After Steve lost 185 pounds, the end of his belt stretched out about 2 to 3 feet. This was a visual reminder that he used every day to check himself when he felt that he had not made the strides that he wanted. Challenge yourself to be creative in finding visual aids that work for you.
• Get the information you need to succeed—find and attend professional workshops in:
Self-esteem
Body Image
Boundary Setting & Assertiveness Training
Relationships, pre and post surgery
Healthy thinking can start prior to surgery, with awareness of issues regarding self-esteem and body image. Go to workshops and support group meetings, and try things at home to help begin to make the changes necessary for success. These emotional, cognitive and behavioral changes are probably as important to our wellbeing as the exercise, nutritional and dietary changes are to our weight loss success. Ultimately, the inability to make changes in either of these areas may result in our failure in the long-term.
Dr. Donna Redmayne is educated in Clinical Psychology, with an emphasis in Neuropsychology. She has worked with inmates at California Men’s Colony, and with brain injury victims in private practice. Donna had Roux en Y gastric bypass on July 5, 2000. Since that time she has lost over 150 pounds, started a Support Group for anyone who has had, or is investigating, weight loss surgery, in that endeavor she has worked with hundreds of morbidly obese patients, both pre and post surgery. She became interested in the unique distorted body image of WLS patients after watching many of these patients struggle with this phenomenon. She has been instrumental in bringing a bariatric program to Lancaster Community Hospital, in the Antelope Valley, which is an extensive area in north Los Angeles County in California.
Krista Redmayne graduated cum laude with degrees in English and Liberal Arts. She has since taken extensive coursework in Graphic Arts and Multimedia, with an eye toward writing, illustrating and animating children’s stories. A single mother of a four-year-old son, Kris enjoys using her creativity to teach and entertain young children.
Kris had a Roux en Y gastric bypass on June 24, 2004, after extensive research on both the RNY and the Biliopancreatic Diversion, with Duodenal Switch. She has lost over 140 pounds, at the time of this writing, and has become a trained facilitator for support groups. Having struggled with her own distorted body image, it has become a particular interest for her.
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