Hostname: page-component-8448b6f56d-wq2xx Total loading time: 0 Render date: 2024-04-23T07:34:45.171Z Has data issue: false hasContentIssue false
  • English
  • Français

Obesity and Internalized Weight Stigma: A Formulation Model for an Emerging Psychological Problem

Published online by Cambridge University Press:  04 September 2013

Denise Ratcliffe  and
Nell Ellison
Denise Ratcliffe*
Affiliation:
CNWL NHS Foundation Trust, and Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
Nell Ellison
Affiliation:
University College London, UK
*
Reprint requests to Denise Ratcliffe, Consultant Clinical Psychologist, Psychological Medicine Unit, South Kensington and Chelsea Mental Health Unit, 1 Nightingale Place, Chelsea and Westminster Hospital, London SW10 9NG, UK. E-mail: d.ratcliffe@nhs.net
Get access Rights & Permissions [Opens in a new window]

Abstract

Background: Obese individuals frequently experience weight stigma and this is associated with psychological distress and difficulties. The process of external devaluation can lead to negative self-perception and evaluation and some obese individuals develop “internalized weight stigma”. The prevalence of weight stigma is well established but there is a lack of information about the interplay between external and internal weight stigma. Aims: To synthesize the literature on the psychological effects of weight stigma into a formulation model that addresses the maintenance of internalized weight stigma. Method: Current research on the psychological impact of weight stigma was reviewed. We identify cognitive, behavioural and attentional processes that maintain psychological conditions where self-evaluation plays a central role. A model was developed based on clinical utility. Results: The model focuses on identifying factors that influence and maintain internalized weight stigma. We highlight the impact of negative societal and interpersonal experiences of weight stigma on how individuals view themselves as an obese person. Processing the self as a stigmatized individual is at the core of the model. Maintenance factors include negative self-judgements about the meaning of being an obese individual, attentional and mood shifts, and avoidance and safety behaviours. In addition, eating and weight management behaviours become deregulated and maintain both obesity and weight stigma. Conclusion: As obesity increases, weight stigma and the associated psychological effects are likely to increase. We provide a framework for formulating and intervening with internalized weight stigma as well as making therapists aware of the applicability and transferability of strategies that they may already use with other presenting problems.

Keywords

Case formulationcognitive behaviour therapyobesitysocial anxietyshameself-esteem
Type
Research Article
Information
Behavioural and Cognitive Psychotherapy , Volume 43 , Issue 2 , March 2015 , pp. 239 - 252
Copyright
Copyright © British Association for Behavioural and Cognitive Psychotherapies 2013 

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Allison, D. B., Basile, V. C. and Yuker, H. E. (1991). The measurement of attitudes toward and beliefs about obese persons. International Journal of Eating Disorders, 10, 599–607.3.0.CO;2-#>CrossRefGoogle Scholar
Almeida, L., Savoy, S. and Boxer, P. (2011). The role of weight stigmatization in cumulative risk for binge eating. Journal of Clinical Psychology, 67, 278–292.CrossRefGoogle ScholarPubMed
Atlantis, E. and Baker, M. (2008). Obesity effects on depression: systematic review of epidemiological studies. International Journal of Obesity, 32, 881–891.CrossRefGoogle ScholarPubMed
Bell, S. K. and Morgan, S. N. (2000). Children's attitude and behavioural intentions towards a peer presented as obese: does a medical explanation for the obesity make a difference? Journal of Paediatric Psychology, 25, 137–145.CrossRefGoogle Scholar
Benas, J. S. and Gibb, B. E. (2008). Weight-related teasing, dysfunctional cognitions, and symptoms of depression and eating disturbances. Cognitive Therapy Research, 32, 143–160.CrossRefGoogle Scholar
Brownell, K. (2010). The humbling experience of treating obesity: should we persist or desist? Behaviour Research and Therapy, 48, 717–719.CrossRefGoogle ScholarPubMed
Carr, D. and Friedman, M. A. (2005). Is obesity stigmatizing? Body weight, perceived discrimination and psychological wellbeing in the United States. Journal of Health and Social Behaviour, 46, 244–259.CrossRefGoogle ScholarPubMed
Christensen, P. N., Stein, M. B. and Means-Christensen, A. (2003). Social anxiety and interpersonal perception: a social relations model analysis. Behaviour Research and Therapy, 41, 1355–1371.CrossRefGoogle Scholar
Clark, D. M. and Wells, A. (1995). A cognitive model of social phobia. In Heimberg, R. G., Liebowitz, M. R., Hope, D. A. and Schneier, I. (Eds.), Social Phobia: diagnosis, assessment and treatment (pp. 69–93). New York: Guilford Press.Google Scholar
Cooley, C. H. (1956). Human Nature and the Social Order. New York: Free Press.Google Scholar
Cooper, Z., Doll, H., Hawker, D. M., Byrne, S., Bonner, G., Eeley, G., et al. (2010). Testing a new cognitive behavioural treatment for obesity: a randomised controlled trial with three-year follow up. Behaviour Research and Therapy, 48, 706–713.CrossRefGoogle ScholarPubMed
Crandall, C. S. (1994). Prejudice against fat people: ideology and self-interest. Journal of Personality and Social Psychology, 66, 882–894.CrossRefGoogle ScholarPubMed
Daníelsdóttir, S., O'Brien, K. S. and Ciao, A. (2010). Anti-fat prejudice reduction: a review of published studies. Obesity Facts, 3, 47–58.CrossRefGoogle ScholarPubMed
Davis-Coelho, K., Waltz, J. and Davis-Coelho, B. (2000). Awareness and prevention of bias against fat clients in psychotherapy. Professional Psychological Research Practice, 6, 682–684.CrossRefGoogle Scholar
Davison, K. K., Schmalz, D. L., Young, L. M. and Birch, L. L. (2008). Overweight girls who internalize fat stereotypes report low psychosocial well-being. Obesity, 16, 30–38.CrossRefGoogle ScholarPubMed
DeJong, W. (1980). The stigma of obesity: the consequences of naive assumptions concerning the causes of physical deviance. Journal of Health and Social Behaviour, 21, 75–87.CrossRefGoogle ScholarPubMed
Durso, L. E., Latner, J. D., White, M. A., Masheb, R. M., Blomquist, K. K., Morgan, P. T., et al. (2012). Internalized weight bias in obese patients with binge eating disorder: associations with eating disturbances and psychological functioning. International Journal of Eating Disorders, 45, 423–427.CrossRefGoogle ScholarPubMed
Fairburn, C. (2008). Cognitive Behaviour Therapy and Eating Disorders. New York: Guilford.Google ScholarPubMed
Fairburn, C. G., Welch, S. L., Doll, H. A., Davies, B. A. and O'Connor, M. E. (1997). Risk factors for bulimia nervosa: a community-based, case-control study. Archives of General Psychiatry, 54, 509–517.CrossRefGoogle ScholarPubMed
Fennell, M. J. V. (1997). Low self-esteem: a cognitive perspective. Behavioural and Cognitive Psychotherapy, 25, 1–25.CrossRefGoogle Scholar
Fennell, M. and Jenkins, H. (2004). Low self-esteem. In Bennett-Levy, J., Butler, G., Fennell, M., Hackmann, A., Muellerand, M. and Westbrook, D. (Eds.), Oxford Guide to Behavioural Experiments in Cognitive Therapy (pp.413–432). New York: Oxford University Press.CrossRefGoogle Scholar
Friedman, K. E., Ashmore, J. A. and Applegate, K. L. (2008). Recent experiences of weight-based stigmatization in a weight loss surgery population: psychological and behavioral correlates. Obesity, 16, 69–74.CrossRefGoogle Scholar
Gariepy, G., Nitka, D. and Schmitz, N. (2010). The association between obesity and anxiety disorders in the population: a systematic review and meta-analysis. International Journal of Obesity, 34, 407–419.CrossRefGoogle ScholarPubMed
Gilbert, P. (1997). The evolution of social attractiveness and its role in shame, humiliation, guilt and therapy. British Journal of Medical Psychology, 70, 113–147.CrossRefGoogle ScholarPubMed
Gilbert, P. (2010). Compassion Focused Therapy. Hove: Routledge.CrossRefGoogle Scholar
Greenleaf, C., Chambliss, H., Rhea, D., Martin, S. and Morrow, J. J. (2006). Weight stereotypes and behavioural intentions toward thin and fat peers among White and Hispanic adolescents. Journal of Adolescent Health, 39, 546–552.CrossRefGoogle ScholarPubMed
Griffiths, K. M., Christensen, H., Jorm, A. F., Evans, K. and Groves, C. (2004). Effect of web-based depression literacy and cognitive–behavioural therapy interventions on stigmatising attitudes to depression: Randomised controlled trial. The British Journal of Psychiatry, 185, 342–349.CrossRefGoogle ScholarPubMed
Hackmann, A., Clark, D. M. and McManus, F. (2000). Recurrent images and early memories in social phobia. Behaviour Research and Therapy, 38, 601–610.CrossRefGoogle ScholarPubMed
Hayes, S. C., Luoma, J. B., Bond, F. W., Masuda, A. and Lillis, J. (2006). Acceptance and commitment therapy: model, processes and outcomes. Behavior, Research and Therapy, 44, 1–25.CrossRefGoogle ScholarPubMed
Hebl, M. R., Ruggs, E. N., Singletary, S. L. and Beal, D. J. (2008). Perceptions of obesity across the lifespan. Obesity, 16, 46–52.CrossRefGoogle ScholarPubMed
Herek, G. M., Capitanio, J. P. and Widaman, K. F. (2003). Stigma, social risk, and health policy: public attitudes toward HIV surveillance policies and the social construction of illness. Health Psychology, 22, 533–540.CrossRefGoogle ScholarPubMed
Jackson, T. D., Grilo, C. M. and Masheb, R. M. (2000). Teasing history, onset of obesity, current eating disorder psychopathology, body dissatisfaction and psychological functioning in binge eating disorder. Obesity Research, 8, 451–458.CrossRefGoogle ScholarPubMed
Karasu, S. R. and Karasu, T. B. (2010). The Gravity of Weight: a clinical guide to weight loss and maintenance. Washington, DC: American Psychiatric Publishing Inc.Google Scholar
Klaczynski, P., Goold, K. W. and Mudry, J. J. (2004). Culture, obesity stereotypes, self-esteem and the “thin ideal”: a social identity perspective. Journal of Youth and Adolscence, 33, 307–317.CrossRefGoogle Scholar
Knight, M. T. D., Wykes, T. and Hayward, P. (2006). Group treatment of perceived stigma and self-esteem in schizophrenia: awaiting list trial of efficacy. Behavioural and Cognitive Psychotherapy, 34, 305–318.CrossRefGoogle Scholar
Kristeller, J. B. and Hallett, B. C. (1999). An exploratory study of a meditation-based intervention for binge eating disorder. Journal of Health Psychology, 4, 357–363.CrossRefGoogle ScholarPubMed
Latner, J. D., O'Brien, K. S., Durso, L. E., Brinkman, L. A. and MacDonald, T. (2008). Weighing obesity stigma: the relative strength of different forms of bias. International Journal of Obesity, 32, 1145–1152.CrossRefGoogle ScholarPubMed
Lau, G., Moulds, M. L. and Richardson, R. (2009). Ostracism: How much it hurts depends on how you remember it. Emotion, 9, 430–434.CrossRefGoogle Scholar
Lehman, A. K. and Rodin, J. (1989). Styles of self-nurturance and disordered eating. Journal of Consulting and Clinical Psychology, 57, 117–122.CrossRefGoogle ScholarPubMed
Lillis, J., Hayes, S. C., Bunting, K. and Masuda, A. (2009). Teaching acceptance and mindfulness to improve the lives of the obese: a preliminary test of a theoretical model. Annals of Behavioral Medicine, 37, 58–69.CrossRefGoogle ScholarPubMed
Link, B. G., Struening, E. L., Neese-Todd, S., Asmussen, S. and Phelan, J. C. (2002). On describing and seeking to change the experience of stigma. Psychiatric Rehabilitation Skills, 6, 201–231.CrossRefGoogle Scholar
Livingston, J. D. and Boyd, J. E. (2010). Correlates and consequences of internalized stigma for people living with mental illness: a systematic review and meta-analysis. Social Science and Medicine, 71, 2150–2161.CrossRefGoogle ScholarPubMed
Luke, M. and Stopa, L. (2009). Psychological theories of the self and their application to clinical disorders. In Stopa, L. (Ed.), Imagery and the Threatened Self (pp.15–64). Hove: Routledge.Google Scholar
Maddox, G. L., Beck, K. W. and Liederman, V. R. (1968). Overweight as social deviance and disability. Journal of Health and Social Behaviour, 9, 287–298.CrossRefGoogle ScholarPubMed
MacInnes, D. L. and Lewis, M. (2008). The evaluation of a short group programme to reduce self-stigma in people with serious and enduring mental health problems. Journal of Psychiatric and Mental Health Nursing, 15, 59–65.CrossRefGoogle Scholar
Mathes, W. F., Brownley, K. A., Mo, X. and Bulik, C. M. (2009). The biology of binge eating. Appetite, 52, 545–553.CrossRefGoogle ScholarPubMed
Moorey, S. (1996). When bad things happen to rational people: cognitive therapy in adverse life circumstances. In Salkovskis, P. (Ed.), Frontiers of Cognitive Therapy (pp. 450–469). New York: Guilford.Google Scholar
Myers, A. and Rosen, J. C. (1999). Obesity, stigmatization and coping: relation to mental health symptoms, body image and self-esteem. International Journal of Obesity, 23, 221–230.CrossRefGoogle ScholarPubMed
Padeksy, C. (1991). Schema as self-prejudice. International Cognitive Therapy Newsletter, 6, 6–7.Google Scholar
Puhl, R. and Brownell, K. D. (2001). Bias, discrimination and obesity. Obesity Research, 9, 788–805.CrossRefGoogle ScholarPubMed
Puhl, R. M. and Brownell, K. D. (2006). Confronting and coping with weight stigma: an investigation of overweight and obese individuals. Obesity, 14, 1802–1815.CrossRefGoogle Scholar
Puhl, R. M. and Heuer, C. A. (2010). Obesity stigma: important considerations for public health. American Journal of Public Health, 100, 1019–1028.CrossRefGoogle ScholarPubMed
Puhl, R., Moss-Racusin, C. A., Schwartz, M. B. and Brownell, K. D. (2008). Weight stigmatization and bias reduction: perspectives of overweight and obese adults. Health Education Research, 23, 347–358.CrossRefGoogle ScholarPubMed
Ramirez, E. M. and Rosen, J. C. (2001). Comparison of weight control versus weight control plus body image therapy for obese men and women. Journal of Consulting and Clinical Psychology, 69, 440–446.CrossRefGoogle Scholar
Reynolds, M. and Brewin, C. R. (1999). Intrusive memories in depression and post-traumatic stress disorder. Behaviour Research and Therapy, 37, 201–215.CrossRefGoogle Scholar
Roberts, R. E., Kaplan, G. A., Shema, S. J. and Strawbridge, W. J. (2000). Are the obese at greater risk for depression? American Journal of Epidemiology, 152, 163–170.CrossRefGoogle ScholarPubMed
Rosenberger, P. H., Henderson, K. E., Bell, R. L. and Grilo, C. M. (2007). Associations of weight-based teasing and current eating disorder features and psychological functioning in bariatric surgery patients. Obesity Surgery, 17,470–477.CrossRefGoogle ScholarPubMed
Schvey, N. A., Puhl, R. M. and Brownell, K. D. (2011). The impact of weight stigma on caloric consumption. Obesity, 19, 1957–1962.CrossRefGoogle ScholarPubMed
Stein, R. I., Kenardy, J., Wiseman, C. V., Dounchis, J. Z., Arnow, B. A. and Wilfley, D. E. (2007). What's driving the binge in binge eating disorder? A prospective examination of precursors and consequences. International Journal of Eating Disorders, 40, 195–203.CrossRefGoogle ScholarPubMed
Vartanian, L. R. and Shaprow, J. G. (2008). Effects of weight stigma on exercise behaviour and motivation: a preliminary investigation among college-aged females. Journal of Health Psychology, 13, 131–138.CrossRefGoogle ScholarPubMed
Waller, G., Cordery, H., Corstorphine, E., Hinrichsen, H., Lawson, R., Mountford, V. and Russell, K. (2007). Cognitive Behavioural Therapy for Eating Disorders: a comprehensive treatment guide. New York: Cambridge University Press.Google Scholar
Wang, S. S., Brownell, K. D. and Wadden, T. A. (2004). The influence of the stigma of obesity on overweight individuals. International Journal of Obesity, 28, 1333–1337.CrossRefGoogle ScholarPubMed
Weiner, B., Perry, R. P. and Magnusson, J. (1988). An attributional analysis of reactions to stigmas. Journal of Personality and Social Psychology, 55, 738–748.CrossRefGoogle ScholarPubMed
Wells, A., Clark, D. M. and Ahmad, S. (1998). How do I look with my mind's eye: perspective taking in social phobic imagery. Behaviour Research and Therapy, 36, 631–634.CrossRefGoogle ScholarPubMed
Wild, J., Hackmann, A. and Clark, D. M. (2008). Rescripting early memories linked to negative images in social phobia: a pilot study. Behaviour Therapy, 39, 47–56.CrossRefGoogle ScholarPubMed
Wott, C. B. and Carels, R. A. (2010). Overt weight stigma, psychological distress and weight loss treatment outcomes. Journal of Health Psychology, 15, 608–614.CrossRefGoogle ScholarPubMed
Submit a response

Comments

No Comments have been published for this article.