Abstract
Objective
Body dysmorphic symptoms are one of the most common problems in adolescent girls. The experience of security or insecurity in childhood attachment can be one of the most important fundamental factors affecting the body image and, consequently, body dysmorphic symptoms. However, the mediator role of the body image in the relationship between body dysmorphic and interpersonal attachment styles has not been studied in previous researches. Therefore, the purpose of this study was to investigate the mediating role of body image in the relationship between interpersonal attachment styles and body dysmorphic symptoms.
Method
In a cross-sectional research, 250 adolescent girls from Baqer al-Uloom School in Tabriz, were selected by convenient sampling method. Then, The Multidimensional Body-Self Relations Questionnaire-Appearance Scales (MBSRQ-AS), Body Dysmorphic Metacognitive Questionnaire (BDMCQ) and Collins and Reid's Attachment Styles Scale (RAAS) were used to data collection.
Results
The findings showed ambivalent attachment style was positively related to body image (β=−0.91, p<0.01) The direct effect of ambivalent attachment style on body dysmorphic symptom is significant (β=0.76, p<0.01). The pathway between body image and body dysmorphic symptom is negatively significant (β= -0.75, p<0.01). Also, the hypothesized model has an acceptable goodness-of-fit.
Conclusions
Based on the results, it can be said that in interventions, it is necessary to pay attention to the important role of interpersonal attachment styles and body image in body dysmorphic symptoms.
Keywords: attachment styles, body dysmorphic symptoms, body image, adolescent girls
1. Introduction
People with body dysmorphic symptoms (previously known as dysmorphophobia) as a subgroup of obsessive-compulsion disorder, according to the criteria of the Fifth Edition of the Statistical and Diagnostic Classification (DSM-5, 2013), have one or more major or minor flaws. They indulge in body appearances that they consider to be unpleasant, unsightly, aberrant, or flawed. According to the DSM5, Body Dysmorphic Disorder (BDD) affects 2.4 percent of individuals in the United States (2.5 % in women and 2.2 % in men). Adolescence and early youth are the most common onset ages (DSM-5, 2013). In Iran, few studies have been conducted to investigate the prevalence of BDD. The prevalence of Body Dysmorphic Disorder in adolescent girls in Yazd was found to be 7.1 percent, with the most prevalent age of infection being 17 years old, according to a research (Esnaashari & Daryapour, 2017). In a study run among the orthodontic population, the prevalence of BDD was 5.5 percent. Age was more prevalent in single women and younger patients (Yassaei et al., 2014). In addition, Talaei and colleagues(2009) assessed the prevalence of BDD at 7.4 percent at Mashhad University of Medical Sciences, noting that the frequency of the two genders in the affected and non-infected groups was not significantly different.
In recent decades, research in the literature has been based on the understanding of the development of body image, determined primarily by the influence of social factors (parents, peers, and the media) (Smolak, 2004) and by biological factors (body mass index and mood). Thus, for a long time in literature, the study of the influence of socio-cultural factors on the formation of the body image has prevailed. This has led to social constructivism, in which the earliest attachment relations are eliminated, and substituted with the idea that external sources have direct influence (Bonev & Matanoca, 2021). In reality, the body image should be considered above all in the context of internal representations and the set of fantasies and meanings and understandings of the body, its parts, and functions (Krueger, 1988). In this sense, the image of the body can be thought of as a dynamically and developmentally emerging mental representation of the bodily self. The bodily self and body image are developmental processes that undergo gradual changes associated with maturation, above all during adolescence (Krueger, 2004; Pellerone et al., 2019).
Body image is a multifaceted notion that includes a person's thoughts, perceptions, and ideas about his or her own body (Cash, 1997, 2002). Each person's image of themselves is initially expressed in the shape of a body, which is referred to as the body image (MousaviDiva & Dastnaee, 2018). This image is generated from birth and is completed as a person develops and evolves throughout their lives (EskandarNejad, 2013). Some studies underlined as gender and race seem to have a role in adolescents body image, while parental judgment appears to be more relevant in body image among youngsters, particularly girls (Zoghipaidar et al., 2018). Other studies have highlighted the significance and effect of family, particularly mothers, on girls' body image (Mulkens et al., 2012).
The present research proposes an approach to the body image as a development construct, arising and developing in the attachment relations. Attachment disturbances, as well as attachment disorganization, are defined as the inability to provide security and protection into attachment relationships; these develop through the mechanisms of reflection, sensitive responses to the child’s signals and synchronous relationships. In the first months of human life, the attachment needs are first and foremost the needs of the body, which are satisfied by the responses of the primary caregiver. Infact, the mother defines her baby’s body in the systemic and relationship-based matrix of attachment. This definition of the body also occurs in the tactile delineation, reflection, and resonance of the internal and external bodily experiences.
1.2 Attachment styles and body dysmorphic symptoms
It appears essential to investigate the factors that can influence body image and in particular body dissatisfaction in the framework of attachment theory (Tasca & Balfour, 2014, 2015). Attachment behavior was characterized by Bowlby as follows: The mother's behavior is often what leads to the main caregiver's closeness. The mother's response to the child's conduct has a big influence on how attachment habits develop (Bowlby, 1969). Ainsworth and colleagues (1981) have identified three basic attachment styles as a consequence of the child's interaction with the mother. Secure attachment; in Ainsworth's investigations, children with secure attachments made up the majority of the group (Ainsworth, 1969). Such children have faith that their loved ones will be there for them. Insecure avoidant; when searching the surroundings, children do not pay attention to their loved ones. They are both physically and emotionally independent of the person to whom they are tied (Behrens et al. 2007). The children cannot acquire any feeling of security from the individual to whom he or she is bonded. When interacting with the child, the child often demonstrates attachment behaviors, but is not accepted by the child. Insecure ambivalent; the child will commonly exhibit clingy and dependent behavior, but will be rejecting the attachment figure when they engage in interaction.
According to recent research, attachment is a key role in the development of body dissatisfaction (Bamford & Halliwell, 2009; Cash et al., 2004; Cheng & Mallinckrodt, 2009; McKinley & Randa, 2005). When a child, particularly a girl, imitates her mother's eating or athletic behavior, attachment theory suggests that it shows an effort to be emotionally connected to the mother (Craparo et al., 2018). If the mother reacts negatively to this effort, the daughter is likely to continue acting out (Bex, 2014).
On the contrary, the literature underlines the presence of a significant relationship between secure attachment and positive body image (Bex, 2014; Iacolino et al., 2017). For example, those who had stronger emotional relationships with their mothers were less inclined to institutionalize society's body norms and expressed greater body satisfaction (Heshmati & Pellerone, 2018; Slaton, 2000). This internalization of the security experienced in the relationship allows the individual to build a safe inner refuge. In the first months of human life, attachment needs are primarily bodily needs, which are satisfied by the responses of the primary caregiver. These relationships organize and give meaning to the bodily self. Attachment relationships and subsequent models represent the primary and central basis that contribute to determining physical and mental selves (Krueger, 1988).
Insecure attachment, on the other hand, stimulates the development of a "false bodily self" (Lemma, 2015). Children classified as anxious (ambivalent or avoidant) often have mothers who exhibit difficulty and resistance to making close physical contact. Infants securely attached to their mothers actively seek physical comfort from them after a brief but stressful separation, unlike infant avoidance. Furthermore, it also appears that the experience of fear associated with attachment, which underlies disorganization, is related to the more tangible problematization of the body.
In a recent study of Bonev and Matanova (2021), authors underline that disorganized people compared to organized people (safe or insecure) experience more anxiety about their body and are more likely to problematize their body in a consultative and therapeutic context (e.g., dissatisfaction with appearance; symptomatology of eating disorder, modification of the body surface – cosmetic surgery). People who invest more (psychologically) in their appearance, are anxious about gaining weight and are sensitive to the presence of various physical symptoms were more likely to have had caregivers in their history who could not provide them with the experience of sufficient security. Relationship security implies lower levels of anxiety about weight and less dysfunctional behaviors, such as restricting eating and dieting. Those who problematize their bodies at the level of appearance, weight, investment in a healthy lifestyle, suspicion of the presence of physical symptoms, have not experienced a relationship with the primary caregiver which could provide sufficient relief of physical and mental sensations and allow them to process the affect and thus to desomatize it . In confirmation of this, a study conducted by Salehi et al. (2019) appears interesting. It aimed to determine the roles of emotional patterns, attachment styles and personality traits in body dysmorphic disorders in 273 individuals prone to facial cosmetic surgery. The results of this study showed that conscientiousness in the first stage, attachment avoidant in the second stage, and simplistic view of emotions in the third stage, as well as the control component in the fourth stage, predicted body dysmorphia in women. In this sense, it seems that the lack of sensitivity, spontaneity, responsiveness, and pleasure in the relationship of attachment leads to a stronger investment in the bodily self.
According to research, adolescent attention to body traits is more obvious, and adolescents are more worried about their organs' uneven development in this region (Phillips et al., 2005). According to Li et al. (2020), attachment is critical in assisting adolescents in coping with adolescent challenges; unhealthy attachment patterns in childhood lead to behavioral disorders in adolescents (Bretherton et al., 2008). One research looked at the relationship between adult attachment and eating disorder symptoms, especially weight loss efforts, overeating, and subscales of physical dissatisfaction with the eating disorder list, and found it to be negative (Suldo & Sandberg, 2006). Morgan-Sowada (2018) discovered a significant relationship between attachment and body dysmorphic disorder in his research. Insecure attachment, in particular, was shown to be significantly correlated to body dysmorphic symptoms. Schmitt, Hart and Chow (2021) showed that girls with insecure attachment style were considerably more worried about their weight than girls with secure attachment style in a study evaluating the relation between attachment styles and weight problems in adolescent girls. They indicated no relation between attachment style and current body shape perception. A research Taheri, Amiri and Keshavarzi (2013) in Iran found that people with body dysmorphic symptoms had considerably more avoidant and ambivalent insecure attachment styles.
Despite substantial studies on the relationship between body image and body dysmorphic symptoms, relation between attachment style and body dysmorphic symptoms is not obvious in the previous researches. On the other hand, previous studies, has not revealed the significance of body image in mediating the relationship between attachment styles and body dysmorphic symptoms (figure 1). Being that the experience of security or insecurity in the mother-child interaction seems to play a role in a person's mental image of the body, the attachment style that a person has with their mother as a child and continues into adulthood, appears to play a role in a person's body image. It may also alter how secure or insecure your body feels throughout adolescence. As a result, the current research aimed to investigate the mediating role of body image in relation of attachment style and body dysmorphic symptoms in adolescent girls.
Figure 1.
Hypothetical model of body dysmorphic symptoms in adolescent girls
1.3 The role of metacognitions in the Body Dysmorphism
Individuals' reactions to regulate cognitive system activity are known as metacognitive strategies. These strategies may increase or decrease the intensity of cognitive strategies, as well as improve regulatory processes (Wells & Matthews, 1996). Rachman and Shaffran (1999) were the first to articulate the thought-action fusion and the objectification of thinking. The thought-action fusion refers to the concept that troubling thoughts and mental pictures might have a direct impact on external occurrences. The opinions and hypotheses that individuals hold about themselves are referred to as metacognitive positive and negative beliefs. These are beliefs about the significance of specific sorts of thoughts and beliefs, such as worrying about pleasant outcomes and avoiding danger, and they may be positive or negative (Cartwright-Hatton & Wells AJJoad, 1997). For example, avoiding social settings are examples of safety practices that preserve cognitive mistakes and do not address metacognitive beliefs (Veale, 2004).
Metacognitive processes towards the body have been largely overlooked as potential risk factors for body dysmorphic disorder (BDD) despite theorizing that a negative body image may play a critical role in the development of this disorder. In order to have a deeper understanding of the processes underlying psychopathological process of BDD, it is necessary to examine cognitive mechanisms involved in the knowledge, interpretation, and regulation of thinking. These mechanisms comprise the domain of ‘metacognition’, that refers to the psychological structures, beliefs, events and processes that are involved in the control, modification and interpretation of thoughts. All these constructs interact in maintaining maladaptive cognition and behavior in the metacognitive conceptualization of psychological dysfunction.
In particular, the self-regulatory executive function (S-REF) theory (Wells et al., 2011), identifies two basic components of metacognition, that influence the possible presence of psychopatholoy: knowledge and regulation. The metacognitive knowledge consists of the beliefs an individual holds about the course and consequences of cognitive enterprises. This knowledge may be accurate or inaccurate, explicit or implicit, and can be triggered unintentionally by retrieval cues (Wells, 2019). Metacognitive regulation involves executive functions such as planning, resource allocation, monitoring, and correcting of cognitive events. According to the S-REF theory, psychological disorder is associated with dysfunction of this system, that is when the regulation and knowledge processes become maladaptive (Wells et al., 2011). In detail, Wells and Matthews (1996) show that a psychological disturbance can be maintained by a combination of perseverative thinking styles, maladaptive attentional routines, and dysfunctional behaviors.
According to the S-REF theory, metacognitive beliefs have been found to be positively associated with many psychological disorders such as depression obsessive-compulsive symptoms, and body dysmorphic disorder. In detail, Cooper and Osman (2007) suggested that patients with BDD, engage in metacognitive processing in relation to their concerns with appearance. In their study, patients reported attempts to distract themselves from their (invariably distressing) images, which had few advantages and many disadvantages, because their images increased self-consciousness and decreased self-confidence. Although some patients, for example, sought to counter their distress by recalling past positive memories, all patients made negative self-judgments as a result of having these images. All patients made negative self-judgments as a result of having these images.
To confirm this, a research conducted by Georgiopoulos and Donovan (2015) which involved a non-clinical group of 635 participants (304 males and 331 females) appears interesting. The data supported the role of body image and meta-preoccupation as mediators of the relationship between cognitive, metacognitive beliefs and body dysmorphic disorder (BDD). These results provide further evidence that body image may represent a necessary but not sufficient risk factor for BDD. For the aforementioned reasons, treatment for BDD should consider targeting body-related pathology in addition to meta-concern.
Similarly, research conducted by Zeinodini and colleagues (2016) has measured the relation between Dysfunctional Metacognitive Beliefs and Body Dysmorphic Disorder in a group of 155 adolescent students aged between 12 and 17 years who were selected through convenient sampling from three high schools, which are governmental educational centers in Isfahan (2013-2014). Results shows the presence of correlation between metacognitive components, thought confusion, meta-worry and body dysmorphic disorder. Furthermore, data underlines the predictive role of metacognitive beliefs (about the meaning, importance, and peril of intrusive thoughts), worry and metacognition components (cognitive confidence, positive beliefs about worry, cognitive self-consciousness, negative beliefs about thoughts and danger which are out of control, and beliefs about demand to control thoughts) on Obsessive Compulsive traits in BDD.
Thus, as suggested by Veale (2004), metacognition may be an important feature of information processing in BDD and one of the ways in which the symptoms of the disorder are suppressed. Imagery has a particularly important role in the maintenance of BDD, where mental self-images are thought to be a particularly central feature of a cognitive conceptualization. Veale’s model, outlined above, needs to be modified to include metacognitive beliefs and mental strategies of thought control. A proposed revised model would begin with a trigger (the sight of oneself in a mirror, for example). This would activate a distorted internal image, which in turn would activate beliefs about oneself as an aesthetic object, the importance of appearance itself and the possible advantages of worrying about appearance (positive metacognitive beliefs). These beliefs would increase the attention to the internal image (thereby distorting it further) and also activate appearance-related thoughts pertaining to self-criticism, comparing the future and the past, planning to change appearance and others’ views of one’s appearance.
Literature shows that people with BDD endorsed negative metacognitive beliefs (regarding both the uncontrollability and danger and the responsibility, superstition and punishment associated with thoughts about appearance) more strongly than other people. People with BDD report more use of strategies related to punishments, appraisals, and worries, while the "normal worries" group employed more distraction and sociability control strategies.
People with BDD use significantly less strategies such as avoidance of negative thoughts that are designed to reduce the frequency, intensity, and discomfort associated with thoughts about appearance. Compared to people with ‘normal concerns’, people with BDD reported significantly higher frequency of appearance-related thoughts pertaining to self-criticism and the future.
2. Objective and goals
The present research proposes an approach to the body image as a development construct, arising and developing in the attachment relations. Because the experience of security or insecurity in the mother-child interaction seems to play a role in a person's mental image of the body, the attachment style that a person has with their mother as a child and continues into adulthood, appears to play a role in a person's body image. It may also alter how secure or insecure your body feels throughout adolescence. As a result, the current research aimed to investigate the mediating role of body image in relation to attachment style and body dysmorphic symptoms in adolescent girls.
In particular, we hypothesized that attachment style has a direct effect on body dysmorphic symptoms and an indirect effect through body image. Furthermore, we hypothesize the role of the body image as the mediator in the relationship between body dysmorphic and interpersonal attachment styles.
3. Method
3.1 Participants and procedure
The current research was a correlational study using a statistical population of all 16-18 years old girl students of Tabriz city during the academic year 2020-2021. Using the convenience sampling method 250 students from several high schools of Tabriz city were selected and completed questionnaires. Inclusion criteria consisted of having age between 16 to 18 years. Exclusion criteria included having a history of chronic physical illness, history of substance or alcohol misuse, a personality disorder diagnosis, or a psychotic disorder diagnosis. A semi-structured interview was conducted by the research team to screen for these criteria. The eligible participants completed the MBSRQ, BDMCQ and RAAS. The instructions for answering the items were thoroughly explained and participants were asked to read each item carefully and then select an option based on their beliefs, feelings, experiences and behaviours.
All participants were given both oral information and a written summary of the study and its objectives. Participants were informed that study participation is completely voluntary and if they decide not to participate or to withdraw from the study, they will not encounter any negative consequences.
3.2 Measure
The Multidimensional Body-Self Relations Questionnaire-AS (MBSRQ-AS): This questionnaire (Cash & Pruzinsky, 1990) consists of 69-item self-report inventory for the assessment of self-attitudinal aspects of the body-image construct. In the current research, we were interested in the appearance-related subscales of the MBSRQ and want to administer a shorter version of the instrument that excludes the fitness and health items. Accordingly, we used the 34-item MBSRQ-AS (MBSRQ-Appearance Scales). The MBSRQ-AS was grouped into subscales clustered into five areas: (a) Appearance Evaluation assesses the feelings of physical attractiveness or unattractiveness; satisfaction or dissatisfaction with one's looks (e.g., "I have good physical endurance"). (b) Appearance Orientation evaluates the extent of investment in one's appearance (e.g., "I am not actively doing anything to keep in good shape"). (c) The Body Areas Satisfaction Scale (BASS) approaches body-image evaluation as dissatisfaction-satisfaction with body areas and attributes (e.g., "Looking at me, most people would think I am fat"). (d) The Overweight Preoccupation assesses fat anxiety, weight vigilance, dieting, and eating restraint (e.g., "I am constantly worried that I am or will get fat"). (e) The Self-Classified Weight Scale assesses self-appraisals of weight from “very underweight” to “very overweight (e.g., "I think I weigh too much"). The respondents, when making a self-report, assessed the level of their relationship to the body (Cash & Pruzinsky, 2002). Brown et al. (1990) evaluated and validated the validity of the Body image questionnaire in 1990. It is also stated to have a reliability of 0.81. In an Iranian sample, internal consistency for the subscales of the MBSRQ ranged from 0.67 to 0.85 for males and 0.71 to 0.86 for females (Khodabandeloo et al., 2019). In our study, the MBSRQ had adequate internal consistency (alpha = 0.79).
Body Dysmorphic Metacognitive Questionnaire (BDMCQ): BDMCQ (Rabiei et al., 2012) has 31 items and includes 4 subscale, respectively: (a) Metacognitive control strategies (e.g., "I am always careful about the reaction of others about my deformity"; items 1 to 14). (b) Thought-action fusion (e.g., "When thoughts about my appearance appear, I accept them"; items 15 to 22). (c) Positive and negative metacognitive beliefs (e.g., "Thoughts related to the deformity of my appearance make me take more care of my appearance."; items 23 to 27). (d) Safety behaviors (e.g., " I keep myself away from others as much as possible because of my ugly appearance."; items 28 to 31). This questionnaire is graded on a scale of 1 to 4. In the research of Rabiei et al. (2012) the reliability coefficient (Cronbach's alpha) of the whole questionnaire and its subscales is more than 0.7, indicating that the instrument is reliable. In the present study, internal consistency for BDMCQ was good (alpha = 0.81).
Collins and Read adult attachment scale (RAAS): This scale involves self-assessment of relation building skills, self-description, how to form attachment relations with close attachment figures and consists of 18 items which are marked on a 5-point Likert scale, scores of 0 to 4 are regarded, respectively. The scale involves 3 subscales: secure attachment style (e.g., "I find it relatively easy to get close to people"; items 1, 6, 13, 12, 8, 17), avoidant attachment style (e.g., "I find it difficult to trust others completely"; items 2, 5, 7, 14, 16, 18), and ambivalent attachment style (e.g., "I want to get close to people, but I worry about being hurt"; items 3, 4, 9, 10, 11, 15). Cronbach's alpha for secure, avoidant, and ambivalent subscales was reported to be 0.81, 0.78, and 0.85, respectively. Regarding Cronbach's alpha values are equal to or greater than 0.80 in all cases, the test is greatly valid. Furthermore, in a study in Iran (Pakdaman, 2004) the reliability of test-retest of this scale is 0.95. Internal consistency of RAAS in the current study was good, Cronbach's alpha=0.86.
4. Statistical analysis
First, the Pearson correlation coefficient was calculated to evaluate the relations among the main variables using SPSS 24.0. Second, the SEM procedure was applied to explore whether body image would be of importance in explaining the association between attachment styles and body dysmorphic symptoms in adolescent girls using AMOS version 24.0. We utilized several fit indices to assess the fit of the path model, namely the χ2 test, the Comparative Fit Index (CFI), Tucker Lewis Index (TLI), and the Root Mean Square Error of Approximation (RMSEA). An acceptable fit was indicated by χ2/df ratio of 3 or below, TLI and CFI values of 0.90 or above and RMSEA values of 0.08 or below (Kline, 2005). Finally, the bootstrapping method was used to explore the mediation effect. The bootstrap confidence intervals (CIs) specify whether the effects are significant based on 1000 random samples. If the CIs do not include zero, then the effect is considered significant.
5. Results
The findings for Pearson correlation coefficients are showed in table 1.
Table 1.
Pearson correlation coefficient of main variables
13 | 12 | 11 | 10 | 9 | 8 | 7 | 6 | 5 | 4 | 3 | 2 | 1 | |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|
1 | 1.RAAS | ||||||||||||
1 | .438** | 2.Secure | |||||||||||
1 | .121 | .342** | 3.Avoidant | ||||||||||
1 | -.157* | -.120 | .742** | 4.Ambivalent | |||||||||
1 | .369** | -.072 | -.244** | .170* | 5.BDMCQ | ||||||||
1 | .957** | .419** | -.064 | -.226** | .224** | 6.Metacognitive control strategies | |||||||
1 | .830** | .916** | .269** | -.026 | .252** | .099 | 7.Thoughtsaction fusions | ||||||
1 | .723** | .749** | .855** | .317** | -.114 | -.161* | .148 | 8.Positive and negative metacognitive beliefs | |||||
1 | .636** | .583** | .597** | .728** | .188* | -.079 | -.201** | .031 | 9.Safety behaviours | ||||
1 | -.240** | -.120 | -.325** | -.247** | -.273** | -.132 | .027 | .278** | .033 | 10.MBSRQ | |||
1 | .935** | -.174* | -.017 | -.252* | -.183* | -.192* | -.062 | .037 | .299** | .109 | 11.Self-Classified Weight | ||
1 | .236** | .399** | -.002 | .128 | .100 | .139 | .120 | .066 | .046 | .046 | .061 | 12.Overweight Preoccupation | |
1 | .163* | .267** | .556** | -.311** | .406** | -.420** | -.379** | -.428** | -.289** | .018 | .098 | -.195* | 13.Body Areas Satisfaction |
Note: *p < 0.05. **p < 0.01.
Table 2.
Fitness indices of the Measurement and the Structural model
Models | RMSEI | CFI | TLI | χ2 | χ2 /df |
---|---|---|---|---|---|
Measurement model | 0.7 | 0.93 | 0.91 | 88.51 | 2.4 |
Structural model | 0.6 | 0.98 | 0.96 | 56.18 | 2.8 |
The results of the correlation coefficient indicate that there is a relation between attachment styles and body dysmorphic symptoms (r= and direct relation. It means that with the increase of attachment styles, the body dysmorphic symptoms also increase. A negative and significant relation existed between body image and body dysmorphic symptoms (r-0.27, p<0.01). = 0.17, p<0.05). It is a positive
Body dysmorphic symptoms also exhibits a negative and significant relation with the component of secure attachment style (r=0.37, p<0.01). 0.24, p<0.01). The component of ambivalence, on the other hand, has a direct and positive relation with the body dysmorphic symptoms (-r= There is a negative andsignificant relationship between the component of the self-classified weight and the dysmorphic symptoms (r-0.19, p<0.05). There is also a negative relationship = between the component of body areas satisfaction and body dysmorphic symptoms (r = -0.43, p<0.01).
5.1 Evaluation of the measurement and structural model
The measurement model was examined before the proposed structural model was validated. The acceptable factor loading is above 0.3 (Agnew, 1991), and the insignificant measured variables can be removed to improve the final model. In addition, since it is a theoretical error to identify two distinct attachment categories for generating a latent factor; we did not include secure attachment in the final model. The results indicated that the measurement model had a poor fit to data: χ2 =121.14, χ2 /df=3.19, TLI=0.83, CFI=0.86, RMSEA=0.10. The standard factor loadings of overweight preoccupation and appearance orientation subscale from the MBSRQ-AS and avoidant subscale from RASS were not significant, so they were removed from the final model. Removing these paths from the model resulted in a good fit as indicated by the following goodness of statistics: χ2=88.51, χ2 /df=2.4, TLI=0.91, CFI=0.93, RMSEA=0.07.
The proposed model tested whether ambivalence attachment style has a direct effect on body dysmorphic symptom and an indirect effect through body image. Fit indices showed acceptable goodness-of-fit for hypothesized mediational model (χ2=56.18, χ2/df=2.8, TLI=0.96, CFI=0.98, RMSEA=0.06).
As shown in table 3 and figure 2, results indicated that ambivalence attachment style was positively related to body image (β=−0.91, p<0.01). The direct effect of ambivalence attachment style on body dysmorphic symptom is significant (β=0.76, p<0.01). The pathway between body image and body dysmorphic symptom, on the other hand, is negatively significant (β= -0.75, P<0.01).
Table 3.
Path coefficients among variables
Sig. | T | SE | Β | B | Variables |
---|---|---|---|---|---|
0.001 | 2.30 | 0.81 | 0.76 | 1.87 | Attachment Body dysmorphic |
0.001 | 2.08 | 3.41 | 0.91 | 7.12 | Attachment Body image |
0.001 | -3.25 | 0.46 | -0.75 | -1.5 | Body Body image dysmorphic |
Figure 2.
Tested model of body dysmorphic symptom in adolescent girls
Table 4.
The result of indirect effect
Independent | Mediator | Dependent | bootstrap samples | Β | 95% Bias corrected CI |
---|---|---|---|---|---|
Upper bound-Lower bound | |||||
Attachment | body image | Body dysmorphic | 1000 | 0.63- | -1.09 to -28.76 |
Note. CI=confidence interval
5.2 Indirect Effect of attachment styles on body dysmorphic symptoms via body image
Indirect effects in the model were tested with a bootstrap procedure. Examination of the 95% bias-corrected confidence intervals (CI) from 1,000 bootstrap samples revealed that the indirect effect of attachment styles (β=-0.63, CI: -1.09 to -28.76) on body dysmorphic symptom through body image was significant. Consistent with our hypothesis, body image was indeed a partial mediator, and this mediation remained significant after controlling for demographical variables.
6. Discussion
The present research investigated the structural pattern of relations between body dysmorphic symptoms, interpersonal attachment styles, and body image in adolescent girls.
The preliminary analysis underlines the presence of a relation between attachment styles and body dysmorphic symptoms; in particular body dysmorphic symptoms seem to be correlated to a secure attachment style positively, but with an ambivalent attachment style negatively. Furthermore, body dysmorphic symptoms seem to be negatively correlated to the functional body image, the component of the self-classified weight and the body areas satisfaction. Data underlines as attachment plays a crucial role in assisting adolescents in dealing with adolescent challenges and insecure attachment style in childhood leading to behavioral problems in adolescence (Heshmati & Pellerone, 2018; Pellerone et al., 2019). The insecure attachment makes it hard for a person to feel secure with his/her caregiver, and he/she continues to feel insecure about his body beyond adolescent. Similarly, during adolescence, the avoidant attachment makes it difficult for a person to accept little indications and symptoms that signal body dysmorphic symptoms. Conversely, research findings also support that individuals with healthy and secure attachments to primary care providers are also less likely to develop mental health problems and to recover from mental illness symptoms at a faster rate (Adam et al., 2004).
Furthermore, correlation analyses show that the secure attachment style is correlated to the metacognitive control strategies, thoughts-action fusions, positive and negative metacognitive beliefs and safety behaviours; furthermore, these metacognitive components of the body dysmorphic disorder seem to be negatively correlated to the ambivalence attachment style. Data confirms the study of Cooper and Osman who observe that patients with BDD tend to use numerous control metacognitive strategies such us attempts to distract themselves from their images, which had few advantages and many disadvantages, because their images increased self-consciousness and decreased self-confidence. Other patients, in order to counter their distress, recalled past positive memories, but as a result of having these images, they made negative self-judgments. The literature therefore agrees in affirming the role of metacognition components (such as cognitive confidence, positive beliefs about worry, cognitive self-consciousness, negative beliefs about thoughts and danger which is out of control, and beliefs about demand to control thoughts) on obsessive compulsive traits in BDD (Zeinodini et al., 2016). In particular, using these strategies, we are often faced with failure since negative efforts to control and eliminate cognitions often increase rather than decrease the amount of negative cognitions. Thoughts and worries often automatically enter into our minds, i.e., they are not under voluntary control and an attempt to control them will usually be subject to failure.
Confirming to the first research hypothesis, the ambivalence attachment style has a direct effect on body dysmorphic symptoms and an indirect effect through body image. The path coefficients reveal that the relationship between attachment styles with body image is considerably more important in the model than the relationship between body image with body dysmorphic. The family climate, and particularly the child's early interaction with the mother, seems to have greater influence in influencing body image, indicating that the attachment style should be correctly viewed as an exogenous variable.
Confirming the last hypothesis, the body image acts as a mediator between attachment and body dysmorphic. This data implies that body image may be able to explain the relationship between attachment and body dysmorphic., as confirmed by international literature (Behzadipour, 2010; Khorshidi & Aghdam, 2018; Orzolek-Kronner, 2002). The adolescent creates an ideal image in response to the rejection of the body image, and the adolescent attempts to transform his body in order to reach this mental ideal, which does not correlate to his real image. In fact, a person's lack of security experience permits them to acquire security by imagining a mental and imagined picture that is out of reach. While, adolescent girls with secure attachment style have a more positive body image themselves. On the other hand, during the first year of life, the child develops expectations and rules that differentially reflect and receive reciprocal attachment behaviors to the caregiver. These expectations are internally organized in the child as active models of the physical environment, attachment, and self-organization. Capacities for emotional regulation and for integration of self-states are correlated to experiences with caregivers during childhood and resulting attachment style (Musetti et al., 2018). Bowlby's main belief was that the child should experience warmth, intimacy, and an ongoing relationship with the mother (or mother's constant successor) in order to experience satisfaction and pleasure (Bowlby, 1979). The role of the second parent (often the father) is to provide the necessary emotional support to the person who is "mothering" the child. The child develops his initial consciousness and understanding of himself via his body. The child will not build a solid relation if the main caregiver, who is generally the mother, adopts a persistent pattern of chilly and rejecting conduct, and the child will ultimately infer that it is not good enough. This weakness in the child's analysis, who identifies with his body, leads to the conclusion that he is unhappy with his body. During development, this mental plan takes root in the child's psyche, which is linked to puberty crises in adolescence. For adolescent girls in particularly, they find it challenging to perceive puberty-related changes as positive body image. They are worried about their appearance (Boursier & Gioia, 2020; Ebrahimi et al., 2016). The process of identification between daughters and mothers never stops since they are of the same sex, which is not the case with the relation between mothers and sons. Therefore, the quality of the mother-daughter relation is critical in identifying girls in several physical and psychological aspects. Now, whether the adolescent girl gets disapproving signals from her mother about her looks, or if the girl perceives disapproval from her, unrealistic conventional standards of beauty are mostly to blame for body dissatisfaction. As a result of the complete combination of these causes, body dysmorphic may result (Zarshenas et al., 2010).
The findings of this research revealed that body image perception predicts body dysmorphic symptoms. The negative of this relationship implies that adolescent girls with a positive body image score higher on a measure of body dysmorphic symptoms. Body dissatisfaction in adolescent girls is influenced by the disparity between the internalized ideal and the mental picture of the body. Body dysmorphic disorder is caused by issues with processing that appear in the absence of positive body cognitions. This conclusion indicates that misperception of the body is a key predictor of body dysmorphic symptoms, in the sense that mental perception and wrong image of body is a precursor of the emergence of body symptoms.
7. Conclusion
The present results suggest that body image is the key factor in explaining why adolescent girls are more prone to body dysmorphic symptoms. Therefore, by intervening in body image and reducing it, the effect of attachment style on body dysmorphic symptoms can be reduced in adolescent girls.
The importance of attachment style as a basic factor in determining body image is demonstrated in this study, indicating that in order to prevent the occurrence of symptoms of body dysmorphic disorder, proper training on improving the quality of the mother-child relationship should be provided to the parents so that the child can develop a proper understanding and image of his body in a safe climate. For example, individuals with BDD whose parents place great emphasis on appearance give the message that one’s appearance is a measure of one’s self-worth; this idea of appearance equaling self-worth becomes a working model of oneself and perpetuates symptoms of BDD in their children (Morgan-Sowada & Gamboni 2021).
On the other hand, this result proposes that in the treatment of adolescents with the disorder or symptoms of body dysmorphic, it is required to initially experience a safe therapeutic relation with the therapist, being in such a safe climate in order to correct misunderstandings of his body image.
The literature shows how family therapy can be a valid aid in children and adolescents with BDD (Flessner et al., 2015); in particular, this therapy would seem effective in reducing the risk of suicidal thoughts and actions in young people (Diamond et al., 2010). Before the potential benefits of family therapy for BDD can be explored, people with BDD need to begin to understand and process lived experiences, to explore the role that relationships and attachment play in development, maintenance and recovery from their BDD symptoms. In fact, understanding the lived experiences of people with BDD, more specifically, investigating how relationships and attachment impact symptoms of BDD, may shed light on therapeutic techniques that both help and hinder this population.
Regardless of findings demonstrating how common BDD is within the general population, the increased risk of suicide for individuals with BDD, and the knowledge that attachment styles create a working model of self - that gives way to how individuals not only view themselves but is also directly linked to depression and suicidality among adolescents - there remains a great paucity of literature studying the ways that relationships and attachment impact BDD symptoms.
In these conclusive reflections, we cannot avoid the need to hope for a greater interest in this issue and into translating the relevant research into action, including further research and prevention.
More research should be conducted in this field, with a focus on, for example, the quantitative and qualitative weight of the influencing factors the BDD, such as peers, parents, and the role of social-media; the type of correlation between personality styles and/ or disorders, the concept of identity and body image should be evaluated to a greater extent.
Based on the results described herein, it is appropriate to emphasise the limits of this work, namely: the absence of a sampling method, which prevents the presence of a representative sample, the generalization of the results, and the external validity; in addition, the absence of a longitudinal-type study design, which is more suitable for research involving adolescents and their identity developments.
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