Mirror, Mirror, on the Wall, I Cannot Guess My Size at All
email to a friend
printer-friendly version| by Donna Redmayne, Ph.D. The reflected image?is it real? Most people have a body image, a mental picture of themselves and an inner sense of satisfaction or dissatisfaction that is based in reality. However, for some, their body image may be extremely distorted. Distorted body image has most commonly been studied in female patients with anorexia or bulimia; however, research is now suggesting that even normal weight women may have a distorted body image. Interviews with several hundred patients who are morbidly obese or have lost dramatic amounts of weight following weight loss surgery (WLS) suggest that a distorted body image is common among many of these patients. Little research has been conducted with the obese regarding body image. How many obese and morbidly obese patients suffer from this syndrome? Ask yourself how many patients exhibit a considerable amount of surprise when they are weighed in the office. This surprise reflects their inability to estimate their weight. Other patients may ?recognize? the number of pounds reflected by the scale, but have a completely inaccurate picture of their body size, because their perception of themselves is distorted. This distorted body image is not restricted to either end of their weight spectrum. They never quite recognize how large they had actually become, nor do they ever accept the true amount of weight they have lost. The Truth Hurts Morbidly obese patients seem to be engaged in a denial of their real size. Frequently, they have tried a multitude of diets, all of which may have produced a loss of weight, only to fail in the end when they gained the weight back, plus more. This pattern of yoyo dieting and the resulting feelings of failure produce extreme emotional pain and an overwhelming sense of shame. In an effort to distance themselves from that pain, the patients repress the awareness of their true body size. Although they recognize that they are overweight, they often fall short of recognizing the actual extent of their obesity. Many will express their intense avoidance of the scale, some even refusing to be weighed by their physician during office visits. They are able to continue in their denial of their weight if they do not see the actual numbers. Avoiding cameras and their reflection in mirrors or windows also indicates this effort to remain in denial of their size. If they are asked to estimate their size using pictures, figures or clothing with the sizes removed, they consistently underestimate the size of their body, choosing clothes that are one or more sizes too small. Although these patients are refusing to recognize the extent of their obesity, they are also in extreme distress. They acknowledge that they are ?fat,? they just do not want to know how ?fat? they are. They still suffer from depression, low self-esteem and extreme dissatisfaction with their body image. Pseudo-Size Me Patients 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 rapid. For these people, their experience, often life-long, has been that they were ?super-sized.? Suddenly, they are at or approaching an average weight, maybe for the first time in their lives. This time, given the option of choosing a picture, figure, or clothing that they believe represents their body size, they will regularly overestimate, thinking that they are larger then they are in reality. Some patients consistently choose a size that is two or more sizes larger than what they currently wear. ?Sara? had a very emotional experience at 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 surgeons scale she would have failed completely and would still be at her pre-surgical weight of 370 pounds. Her mental picture of herself was still at this pre-surgical size. The Broken Image How does this distorted body image affect patient health and safety? The inability to perceive their actual body size increases the patients? risk of resistance to medical and psychological treatment. Morbidly obese patients who are in denial may resist treatment of their obesity. This may mean that they ignore symptoms of obesity-related illnesses, putting off treatment for diabetes, hypertension, sleep apnea and other life threatening disorders. Often they avoid seeking medical treatment, only seeing a physician when their symptoms become so extremely severe that they can no longer ignore them. While denying the consequences of their obesity, the patients will still often suffer from depression, which may produce feelings of helplessness and hopelessness. If they feel nothing can be done?every diet has failed? why try? The patients feel very self-conscious and worry about ?fitting in,? whether it is literally fitting in a theater seat or a restaurant booth or fitting in at the gym or at a party surrounded by ?thinner? people. They may choose social isolation to avoid public judgment and embarrassment. They will also avoid many other activities that are difficult because of their size. Joint pain may preclude movement, and they feel out-of-place engaging in recreational events. It is only when they become desperate because of the physical or social limitations that they will finally yield to medical intervention. For some patients, 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 the patient opted for treatment at an earlier stage. Although most of these patients do not fit the full criteria for Body Dysmorphic Disorder (BDD) according to the DSM-IV-TR, they exhibit many of the symptoms. Both at their high weight and after weight loss, the patients are preoccupied with their weight and overall body size. They are extremely distressed by this preoccupation, sometimes dwelling on their 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,? others avoid mirrors altogether. They constantly compare themselves with others: ?Am I bigger/ smaller than that person?? And they feel that others are constantly judging them, taking special notice of how ?fat? they are. The WLS patients who suffer 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 and perceiving themselves as still ?fat,? sometimes even at goal weight, patients may choose to not eat or to purge by vomiting or taking laxatives, even when they have eaten only small amounts. ?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. Mending the Break Obviously, if patients are having moderate to severe problems with distorted body image and negative sequelae, the best thing we can do is refer them for professional counseling. If the problems are mild and the patients are motivated, help can be offered through bariatric center sponsored workshops, or professionally facilitated support group meetings. If a WLS patient without professional training leads the 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 or obsessive-compulsive disorders. The following are some ideas that can be used with patients, either through workshops or through support groups, to begin to help them make the emotional, cognitive and behavioral changes necessary to be successful in their acceptance of themselves. ■ Discuss genetics with every patient. Help them to understand that their body shape will probably resemble other members of their family. Ask them who they most resemble in body shape and size. They will probably continue to resemble this person as their weight drops. ■ Talk about negative thinking; help the patient to replace negative ?self talk? with positive affirmations. Have them 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 them at first, but after time they will begin to accept their truth. ■ Have the patient think about what situations make them feel ?fat.? Journaling can sometimes help in this effort. After they are aware of these situations, they can choose to avoid them or to find ways to change either the situation or their thinking so that they begin to feel good about themselves in every situation. ■ Teach relaxation and meditation exercises to patients who are extremely anxious or self-critical, helping them to put thoughts and behaviors into the proper perspective. ■ Tell the patient to put ?before? and ?after? pictures adjacent to each other in a prominent place, so that they see the difference regularly. Ultimately, they begin to see the changes they have made. Remind them to change the ?after? picture as they continue to lose weight. ■ If the patient has a place to draw an outline around their body before their surgery, have them do so. This can be on butcher paper, on the garage drywall, anywhere that it is okay to draw on the walls. Then as they lose their weight, they can see a life-size depiction of their pre-surgical self. ■ Using any visual aids helps the patient to begin to accept their new image. ?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 185 pounds lost, the end of the 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 your patients to be creative in finding visual aids that work for them. ■ Give your patients the information they need to succeed: conduct professional workshops in: ? Self-esteem ? Body Image ? Boundary Setting and Assertiveness Training ? Relationships, pre- and post-surgery Healthy thinking can start with the Primary Care Physician prior to surgery, if a good rapport is developed with the patient and the physician understands the patient?s issues regarding self-esteem and body image. The patient can be encouraged, by the physician or through workshops or support group meetings, to try things at home to help them begin to make the changes necessary for success. These emotional, cognitive and behavioral changes are probably as important to the patient?s wellbeing as the exercise, nutritional and dietary changes are to their weight loss success. Ultimately, the inability to make changes in either of these realms may result in the patient?s failure over 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, and been instrumental in bringing a bariatric surgical program to the Antelope Valley. 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. 2005 |
Most Active
Recent Topics
