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When you have body dysmorphic disorder, you intensely focus on your appearance and body image, repeatedly checking the mirror, grooming or seeking reassurance, sometimes for many hours each day. Your perceived flaw and the repetitive behaviors cause you significant distress and impact your ability to function in your daily life.

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It's not known specifically what causes body dysmorphic disorder. Like many other mental health conditions, body dysmorphic disorder may result from a combination of issues, such as a family history of the disorder, negative evaluations or experiences about your body or self-image, and abnormal brain function or abnormal levels of the brain chemical called serotonin.

Previous research has asserted the importance of both body shape (e.g. WHR) and size (e.g. BMI) [10,13,14], but has not addressed the role of fat and muscle composition in determining these size and shape preferences. The reliance on BMI as a measure of body size in research addressing the attractiveness and health of bodies is problematic for two main reasons. First, BMI does not differentiate between fat and muscle, such that two individuals with the same BMI may have very different levels of fat and muscle in their bodies. A recent study found that 29% of people classified as lean using a traditional BMI scale had levels of body fat usually associated with obesity [20]. Conversely, individuals with high muscle mass may be incorrectly classified as obese when using BMI as an index of weight status [21]. Second, the formula underestimates the risk of obesity-related morbidity in shorter people and overestimates this risk in taller people [22].

Men have approximately 60% more muscle mass than women [27,28]. High muscle mass in men is associated with various positive health outcomes, including increased physical fitness, longevity [2,37] and a decreased risk of developing some diseases [38]. High muscle mass in men is also associated with indicators of mating success, including positive body image [19,39,40], and a higher number of sexual partners [28]. Conversely, very high levels of muscularity are associated with up to 50% higher dietary energy requirements [28], and extreme testosterone levels, which increase with muscle mass, and are associated with poor immune system activity [28,41].

A significant interaction was found between composition dimension and body sex, F(1,61) = 645.49, p

Male observers in the current study preferred a lower male body mass for both health and attractiveness trials than did female observers. Although one early and one more recent study found no differences in preferences for male body size and shape as a function of observer sex [11,54], evidence in this regard is limited and these discrepant findings warrant further investigation.

Appearance-related social pressure plays an important role in the development of a negative body image and self-esteem as well as severe mental disorders during adolescence (e.g. eating disorders, depression). Identifying who is particularly affected by social pressure can improve targeted prevention and intervention, but findings have either been lacking or controversial. Thus the aim of this study is to provide a detailed picture of gender, weight, and age-related variations in the perception of appearance-related social pressure by peers and parents.

The results suggest that preventive efforts targeting body concerns and disordered eating should bring up the topic of appearance pressure in a school-based context and should strengthen those adolescents who are particularly at risk - in our study, girls and adolescents with higher weight status. Early adolescence and school transition appear to be crucial periods for these efforts. Moreover, the comprehensive assessment of appearance-related social pressure appears to be a fruitful way to further explore social risk-factors in the development of a negative body image.

Up to now, research has provided important findings on the impact of single types of social pressure and general behavioral mechanisms. However, in order to explain the development of negative body image and design targeted prevention approaches, we must also find out who is particularly faced with social pressure. The following sections will attempt to summarize the knowledge on variations according to individual characteristics considering gender-, age, and weight-related variations.

Developmental theories on the transformation of relationships with peers and parents [28] suggest that social pressure might change throughout adolescence. Further, the gender intensification hypothesis of Hill and Lynch [29] suggests that pressure from peers and parents to conform to gender roles, behavior and appearance standards intensifies during adolescence. However, only a few studies have investigated developmental effects in the field of social pressure and reported a growing influence of friends and an increase in appearance pressure by other peers (e.g., schoolmates) during middle adolescence [1, 7]. In addition, Dohnt and Tiggemann [30] provided interesting findings on the impact of school and class norms among elementary school girls in the first four years of formal schooling. While girls in the first year at school thought that their peers would desire a larger figure, girls from grade two to four already assumed that their peers desired a thinner figure. These results suggest that orientation towards a certain body ideal as well as appearance-related school and class norms develop very early. Interestingly, Chen and Jackson [31] reported an age-gender interaction among a sample of Chinese adolescents, suggesting that appearance conversations between friends might increase with age only among girls but not among boys. However, they could not establish a comparable effect regarding general appearance-related pressure. In contrast to a probable increase in appearance-related interactions, teasing and exclusion proved to be rather stable during adolescence [7]. Jones [1] even found a decrease in reported teasing among adolescents from grades 10 to 11, which indicates that teasing becomes less important with the transition to adulthood.

In summary, more knowledge on variation according to individual characteristics is needed to explain the development of negative body image and to design targeted prevention approaches. While previous studies have provided important findings on the impact of single types of social pressure and general behavioral mechanisms, findings on gender, age and weight variations in different aspects of social pressure have either been incomplete or controversial, because only a few studies have explicitly focused on these individual differences. Moreover, due to restricted sample size most of the studies could not consider possible interactions between the three factors. Finally, research has often concentrated on girls, or when it included boys, the applied measures often contained a bias towards the thin ideal that is not suitable for boys.

The research of the recent years has posed the question whether the emphasis placed on female beauty sets girls at greater risk for appearance-related social pressure or whether these effects have derived from biased instruments that were unsuitable for boys. Even if several studies have pointed to the growing relevance of appearance among boys and some gender differences diminished when studies use muscle- and weight-related instruments, most of the findings suggest that the focus on appearance is still stronger for females. Consequently, we hypothesized that girls would show higher levels of peer pressure through modeling by friends, school and class norms, peer teasing and exclusion as well as higher levels of parental pressure through parental teasing, encouragement to control weight and shape, parental norms and modeling and injustice and ignorance.

Because to our knowledge no instrument exists that measures social pressure from peers and parents simultaneously while distinguishing various types of pressure, we developed the Appearance-Related Social Pressure Questionnaire (FASD, Fragebogen zum aussehensbezogenen sozialen Druck [17]). To gather an accurate measure of social pressure we included on the one hand those social impacts established in the literature and on the other hand conducted qualitative interviews with adolescent girls and boys exploring important sources of social pressure in their daily lives. The literature predominantly provides evidence for comparable risk factors for body concerns in both boys and girls [e.g. [41, 42]. The findings from our interviews during the item generation also pointed to comparable forms of social pressure. However, we had to ensure that the phrases were suitable for both girls and boys as well as for adolescents with different weight statuses. Thus, we used general terms like appearance or body shape and tried to avoid specific ones like thinness to avoid a bias. The 32 items are rated on a 5-point Likert scale from 1 (strongly disagree) to 5 (strongly agree). A series of structural equation models was used to investigate the factor structure of the FASD. The best fitting model revealed two parts (peer and parental pressure), each consisting of four scales that comprise four items, respectively, and ask about different types of appearance-related social pressure.

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