The ‘body bully,’ is the internal voice that can ruin body image — and cause mental illness

“You can’t go to the beach, you look terrible!”

Unfortunately, in Western societies like Australia, many of us will hear words like this inside our heads at some point in our lives. However, when these harsh ramblings persist over time, a person can develop a negative body image and body dissatisfaction.

‘Body bullying’ and poor body image are not only afflictions of young girls and women — older women, boys and men, LGBTQIA+ people and those from culturally diverse groups can all learn to berate their human form.

To illustrate the scale of the problem, a 2023 survey by the Butterfly Foundation reported that more than 90% of young Australians aged 12-18 years had some level of body image concern, with nearly half dissatisfied with the way their body looks. The picture is similar in Australian adults, with a 2017 survey by the same organisation showing that 43.4% of people were dissatisfied with their appearance and 73% wished they could change the way they look.

A contributing factor to this widespread body concern is the proliferation of appearance-focused media, especially social media like Instagram — where edited images and life’s ‘highlights’ portray unrealistic bodies and faces that cannot be achieved in real life.

Risk factors for poor body image

Vulnerability to body dissatisfaction is higher in people:

• Going through certain life stages, such as childhood and adolescence, midlife, puberty and the perinatal period
• Who identify as LGBTQIA+
• Who have low self-esteem, anxiety or depression
• With the following traits: perfectionism, black and white thinking and frequent comparison with others
• With higher body weights, especially if they have been teased or bullied about their weight.

What poor body image can lead to

Bullying our bodies over time can lead to low self-esteem, obesity and mental illness — including body image disorders (less common), eating disorders (more common), and anxiety and depression. It is important to note that poor body image can still significantly negatively impact someone’s life even if a mental disorder has not been clinically diagnosed.

Body image disorders include body dysmorphic disorder (BDD) and a subtype of it called muscle dysmorphia. BDD is classified within the obsessive-compulsive and related disorders in the Diagnostic and Statistical Manual of Mental Disorders (DSM) and involves excessive preoccupation with appearance and related repetitive behaviours that result in clinically significant distress or impairment in functioning. In muscle dysmorphia, there is a specific obsession with perceived inadequate body muscle size.

Negative body image is also intertwined with disordered eating and eating disorders, which can co-exist on a spectrum from healthy behaviours (normal eating and positive body esteem) to clinical eating disorders. Most eating disorders involve body image concerns, such as the intense fear of gaining weight and body shape disturbance in anorexia nervosa, but not always — for example, avoidant and restrictive food intake disorder (ARFID) does not involve any disturbance in body weight or shape evaluation.

Mental illnesses like anxiety and depression not only increase the risk of someone developing negative body image — they can also be caused by a negative body image and can be co-morbid with body image and eating disorders.

The links between body image and mental illness are complex. It can be hard to pinpoint the precise role that negative body image plays in the onset or maintenance of a mental illness — which came first, the chicken or the egg, the mental illness or poor body image? With eating disorders for example, it makes sense that body image disturbance might come first, where someone can become fixated on trying to change their body shape before then progressing into disordered eating or exercise behaviours. When such behaviours do not achieve the desired (often unrealistic) results, people can feel intense disappointment and shame. In any case, body image concerns and certain mental illnesses are intricately linked through a two-way street and co-occurrence.

Signs and symptoms to look out for in patients

GPs can often be a first step that someone may take to get help with body image concerns. It is important to be a compassionate and open listener who doesn’t applaud things like extremely ‘healthy eating’ or a low body weight or an advanced level of fitness.

Signs of poor body image can include: 

• An overvaluation of how important appearance is to self-worth
• Thinking and talking a lot about appearance
• Criticism of people who don’t meet an appearance ideal, e.g., people with higher body weights
• Comparing their appearance negatively with others
• Repetitive dieting behaviour
• Excessive exercise patterns
• Avoiding social situations where they may have to show their body, e.g., swimming
• Low self-esteem
• A conviction that they are unattractive or deformed in some way, including in their level of body fat or muscle, nose size or skin type. This can be associated with obsessive skin picking and cosmetic surgeries.

What to do if you think a patient may have poor body image

Combating poor body image early can constitute the primary prevention of a mental illness like an eating disorder. The InsideOut Institute has an online GP Hub that provides a wealth of information about prevention, screening, diagnosis, treatment, and more — with a focus on eating disorders: https://gp.insideoutinstitute.org.au/  

It links to the Institute’s short 6-question online screening tool that can be completed by anyone aged 14+ years: https://insideoutinstitute.org.au/screener/

It also provides a diagnosis support tool and an online version of the Eating Disorders Examination Questionnaire (EDEQ), which is used to support clinical diagnosis: https://insideoutinstitute.org.au/assessment/.

Its treatment planning guide outlines what psychological, medication and dietetic therapy may be appropriate for who and when (including finding local treatment providers), as well as details on Medicare subsidies for treatment — and formatted care plan templates that can be imported into practice management software for Mental Health Care Plans, GP Management Plans, Team Care Arrangements and Eating Disorder Treatment Plans.

For body image issues that do not seem to have disordered eating features, the National Eating Disorders Collaboration’s factsheet outlines DSM-5 diagnostic criteria and treatment options for BDD: https://nedc.com.au/assets/Fact-Sheets/BDD-fact-sheet.pdf

There are also helplines and extensive online self-help support materials available, which might be particularly useful for patients with milder body image issues or who are hesitant to engage in further treatment right now, or as a supplement to treatment, such as:

• Butterfly | Resources
• National Eating Disorders Collaboration (NEDC) | Resources
• Inside Out (Institute for Eating Disorders) | Resources
• Centre for Clinical Interventions (WA GOV) | Looking after yourself: Self help resources for mental health problems (including self-help workbooks for BDD, appearance concerns, disordered eating, self-compassion and self-esteem)
• Self-Compassion | Self-Compassion Practices: Dr Kristin Neff

With respect to professional development, the InsideOut Institute has an eLearning module called ‘The Essentials: Training Clinicians in Eating Disorders’, which can contribute to CPD.

Finally, some helpful things that you could say to someone presenting with poor body image include the following statements. These words might help a body-bullied patient more than you think:

• It is important for us to focus on your overall health and wellbeing, not your body weight, weight loss, body shape and appearance.
• Food is there to nourish our bodies and keep them healthy, there are no “good” and “bad” foods, and extreme diets can lead to serious problems.
• Exercise should be about strength, functionality and enjoyment.
• We all need to learn to be kinder to ourselves and to treat ourselves like we would a good friend. This is called self-compassion. Would you say the things you say to yourself in your head to a good friend?
• Healthy bodies come in a variety of shapes and sizes — we can’t all look the same (nor would we want to!).

Rebecca Reynolds is the co-author of a new self-help book called Beyond the Body Bully, How to love the body you’re in