375 • Revista Brasileira de Psiquiatria 2010 • vol 32 • nº 4 • dez2010
Posture and body image in individuals with major
depressive disorder: a controlled study
Postura e imagem corporal em indivíduos com depressão: um
Janette Zamudio Canales
Rua Ovídio Pires de Campos 785, 3o. andar, Ala Norte - Cerqueira César
05403-010 São Paulo, SP, Brasil
Phone/fax: (+55 11) 3069-6648
Janette Zamudio Canales,1 Táki Athanássios Cordás,2 Juliana Teixeira Fiquer,3 André Furtado Cavalcante,1
Ricardo Alberto Moreno1
1 Grupo de Doenças Afetivas (GRUDA), Institute and Department of Psychiatry, Universidade de São Paulo Medical School (FMUSP), São
Paulo, SP, Brazil
2 Eating Disorders Program (AMBULIM), Institute and Department of Psychiatry, Universidade de São Paulo Medical School (FMUSP), São
Paulo, SP, Brazil
3 Department of Experimental Psychology, Institute of Psychology, Universidade de São Paulo (USP), São Paulo, SP, Brazil
Objective: In this study, we aimed to quantify posture and body image
in patients with major depressive disorder during episodes and after
drug treatment, comparing the results with those obtained for healthy
volunteers. Method: Over a 10-week period, we evaluated 34 individuals
with depression and 37 healthy volunteers. Posture was assessed based
on digital photos of the subjects; CorelDRAW software guidelines and
body landmarks were employed. Body image was evaluated using the
Body Shape Questionnaire. Results: During depressive episodes (in
comparison with the post-treatment period), patients showed increased
head ﬂexion (p < 0.001), increased thoracic kyphosis (p < 0.001), a
trend toward left pelvic retroversion (p = 0.012) and abduction of the
left scapula (p = 0.046). During remission, patient posture was similar
to that of the controls. At week 1 (during the episode), there were
signiﬁcant differences between the patients and the controls in terms of
head ﬂexion (p < 0.001) and thoracic kyphosis (p < 0.001); at weeks 8-10
(after treatment), such differences were seen only for shoulder position.
The mean score on the Body Shape Questionnaire was 90.03 during the
depressive episode, compared with 75.82 during remission (p = 0.012)
and 62.57 for the controls. Conclusion: During episodes of depression,
individuals with major depressive disorder experience changes in posture
and mild dissatisfaction with body image. The ﬁndings demonstrate that
the negative impact of depression includes emotional and physical factors.
Descriptors: Posture; Depression; Body image; Evaluation; Depressive
Submitted: September 17, 2009
Accepted: January 18, 2010
Objetivo: O objetivo deste estudo foi avaliar quantitativamente a postura
e a imagem corporal em pacientes com transtorno depressivo maior, durante
o episódio depressivo e após tratamento medicamentoso, e comparar com
voluntários sadios. Método: Durante o período de dez semanas, foram
avaliados 34 indivíduos com depressão e 37 voluntários sadios. A postura
foi avaliada através de fotos digitais e do software CorelDRAW. A imagem
corporal foi avaliada através do Body Shape Questionnaire. Resultados: No
episódio depressivo (em comparação ao período pós tratamento), os pacientes
apresentaram aumento da ﬂexão da cabeça (p < 0,001), aumento da cifose
(p < 0,001), retroversão pélvica esquerda (p = 0,012) e abdução da escápula
esquerda (p = 0,046). Na remissão, a postura foi similar ao grupo controle.
Na comparação entre controles e transtorno depressivo maior, houve diferença
para postura da cabeça (p < 0,001) e cifose torácica (p < 0,001). Na remissão
houve diferença para a postura do ombro. A média dos escores do Body Shape
Questionnaire foram 90,03 no episódio e 75,82 na remissão (p = 0,012).
O grupo controle apresentou escore 62,57. Conclusão: Houve diferença da
postura e insatisfação da imagem corporal durante o episódio em indivíduos
com transtorno depressivo maior. Os achados destacam que o impacto negativo
da depressão abrange tanto fatores emocionais quanto físicos.
Descritores: Postura; Depressão; Imagem corporal; Avaliação; Transtorno
Depression is one of the most common psychiatric disorders
in adults and is characterized by depressed mood, changes in
appetite, disturbed sleep, reduced energy, tiredness, fatigue,
anxiety and a lack of motivation.1 Clinical observation suggests
that the appearance of patients with depression is distinct and
recognizable, characterized by sad facial expression, furrowed
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Revista Brasileira de Psiquiatria 2010 • vol 32 • nº 4 • dez2010 • 376
brow, curved shoulders and a lack of spontaneous body
Posture is deﬁned as the position and relative arrangement of
the body parts. The ideal alignment in the vertical posture allows
the body to maintain its balance with a minimum expense of
energy.3 By analogy, bad (or abnormal) posture means the defective
relation among the multiple parts of the body. Postural problems
typically generate higher tension over the supporting structures
which constitute the musculoskeletal system. Posture is inﬂuenced
by a number of conditioning factors: mechanical and emotional
aspects; heredity and race; ﬂexibility; muscle strength; vision;
and habits.4-7 In addition, feelings of excitation, conﬁdence and
satisfaction manifest as an alert attitude and erect posture, whereas
depression typically manifests as a slouching posture.8
Although no standard approach to assessing posture has been
deﬁned, the use of photos has been supported by many studies.9-11
Photogrammetry, deﬁned as the interpretation of obtained values
from a photographic image, is a quantitative technique that allows
the angles and distances between bone references, joints, planes
and axes to be measured, reliably assessing posture and identifying
Self-awareness of posture is linked to the concept of body
image. Posture and body image are closely related. Body image
determines differences and plasticity of the postural organization.
Due to constant changes in position, tactile and visual perceptions
continuously force the remodeling of the posture.12 Body image is
deﬁned as the mental perception of the size, contour and shape of
our bodies, as well as our feelings related to those characteristics
and to the parts that constitute our body. Therefore, body image
has two major components: a perception component, related to
the self-estimated body size, and an attitude component, related
to affect and cognition.13 Body image disturbances are seen in
neurological and psychiatric disorders.
Most reports on the posture of depressed patients have been
observational. In addition, most studies on this topic have assessed
eating disorders or have evaluated only depressive symptoms.14
To our knowledge, there have been no studies quantitatively
evaluating posture and body image in patients with major
depressive disorder (MDD). Therefore, this study aims to evaluate
the posture and body image in individuals with MDD during
episodes and remission, and we compare the results with those
obtained for a control group consisting of healthy volunteers.
This was a 10-week, observational case-control study. Our
sample consisted of 34 individuals with MDD, from 20 to 50
years of age, receiving care at the Mood Disorders Unit of the
Psychiatry Institute of the Universidade de São Paulo Hospital
das Clínicas, a public hospital located in the city of São Paulo,
Brazil. The diagnosis of MDD was made in accordance with the
Diagnostic and Statistical Manual of Mental Disorders, Fourth
Edition (DSM-IV), text revision criteria. A score ≥ 18 on the
17-item Hamilton Rating Scale for Depression (HAM-D-17)
was considered indicative of an episode of depression (week 1),
whereas a HAM-D-17 score ≤ 14 was considered indicative of
partial or total remission (weeks 8-10).
A control group (n = 37) was composed of age- and gender-
matched healthy individuals, identiﬁed from a previous study.15
None of the controls had any family or personal history of
psychiatric disorder as evaluated by the 20-item Self-Reporting
Questionnaire,15 as well as by DSM-IV.15 To rule out clinically
relevant nonpsychiatric disorders, we applied a questionnaire
regarding family history, as well as conducting laboratory tests,
electrocardiograms and physical examinations. The exclusion
criteria were as follows: presenting with a neuromuscular or
musculoskeletal disorder; and exercising regularly (more than
twice a week or more than three hours per week).
The project was approved by the local ethics committee, and the
legal representatives of the subjects gave written informed consent.
To conduct the postural assessments, we used photos of patients
in the orthostatic position (sagittal and frontal planes), as previously
described by Penha et al.16 Height and weight were measured
before the images were taken, and the body mass index (BMI) was
calculated. A room was reserved for posture evaluation and the
patients were asked to stand on a wood base (40×40cm), which was
positioned in front of a grid (2×1m; grid size, 10×10cm).
A digital camera (Cybershot® DSC, 7.2 Megapixels; Sony
Corporation, Tokyo, Japan) was rotated and locked in the vertical
position (90° from horizontal) in order to capture an image of the
entire body. The camera was positioned at a standardized distance
of 2.70 m from the grid and at a height of 1 m. The upper part
of the wood base coincided with the lowest grid line. The camera
was aligned parallel with the ﬂoor through the use of the built-in
For each subject, the following bone reference points were
marked with adhesive dots: lateral malleoli; head of the fibula;
greater trochanter of the femur; anterior and posterior superior
iliac spine; cervical spine (at C7); thoracic spine (at T3, T6,
T9 and T12); lumbar spine (at L3 and L5); sacral spinous
processes; and inferior scapular angle.5 Some of these reference
points were also marked with small balls (15 cm in diameter):
anterior and posterior superior iliac spine; thoracic spine (at
T3, T6, T9 and T12), lumbar spine (at L3 and L5); cervical
spine (at C7); and acromion.5
Photos were imported into the CorelDRAW program, version
12 (Corel, Ottawa, Canada) and were enlarged in order to identify
the reference points. Sagittal plane photos were used in order to
assess head position, shoulder position, thoracic kyphosis, lumbar
lordosis, pelvic inclination and knee position. Posterior plane
photos were used in order to assess scapula and ankle position.
The Body Shape Questionnaire (BSQ) was used in order to
evaluate subject body image. The BSQ consists of a Likert-type
scale, including 34 questions related to concerns regarding body
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377 • Revista Brasileira de Psiquiatria 2010 • vol 32 • nº 4 • dez2010
shape and weight, as well as affective, cognitive and behavioral
aspects, over the past 4 weeks. Rankings are assigned by ordering
the scores obtained by sum of points and categories: ≤ 80 = no
dissatisfaction; 81-110 = mild dissatisfaction; 111-139 = moderate
dissatisfaction; and ≥ 140 = strong dissatisfaction.14
3. Data analysis
The angles between bone reference points were quantiﬁed in
degrees and calculated using the CorelDraw guidelines. Data
collection and measurements were performed by the same
researcher. Measurements were taken twice (right and left sides)
in the frontal, posterior and sagittal planes.16
Head position - In the sagittal plane, a horizontal line was drawn
at C7 and a diagonal line was drawn from the point where that
horizontal line met the spine to the external auditory meatus. We
measured the angle between those two lines (Figure 1).
Thoracic kyphosis - In the sagittal plane, the angle between the
point of greatest cervical concavity and that of greatest lumbar
concavity was measured, the vertex being the highest point of
thoracic convexity (Figure 1).
Lumbar lordosis - In the sagittal plane, the angle between the
highest points of convexity on the thoracic curve and the gluteus
region was measured, the vertex being the point of greatest lumbar
concavity (Figure 1).
Pelvic inclination - In the sagittal plane, a horizontal line was
drawn at the level of the anterior superior iliac spine, which is
the vertex of the angle formed between that horizontal line and a
second line ending at the posterior superior iliac spine (Figure 1).
Knee position - In the sagittal plane, the angle between the
lateral malleoli, the head of the ﬁbula and the greater trochanter
of the femur was measured in order to identify hyperextension
or semi-ﬂexion (Figure 1).
Scapula position - In the posterior plane, the distance below the
corresponding apophysis angle was measured in centimeters, in
order to estimate abduction or adduction of the scapula.
Shoulder position - In the sagittal plane, the distance from the
acromion to the C7 spinous process was measured in centimeters,
in order to identify shoulder protraction (Figure 1).
Ankle position - In the posterior plane, the angle between a
vertical line running through the Achilles tendon and the vertical
line of the leg to the average midpoint of the calcaneus was
Data were analyzed using descriptive statistics and summary
tables. The statistical analysis was performed using the following:
Pearson’s chi-square test to compare proportions between groups
(e.g., gender); the t-test to compare age; the exact chi-square test
for race; and the Mann-Whitney test for BMI. For quantitative
variables, the Kolmogorov-Smirnov test was employed in order
to determine the goodness of ﬁt for normality; the paired t-test
was performed for variables with normally distributed data within
a group; and the Wilcoxon test for paired samples was used for
variables with non-normally distributed data. In the comparison
between groups for postural variables, ANOVA was performed for
normally distributed data and the Mann-Whitney test was used
for non-normally distributed data. The Statistical Package for the
Social Sciences, version 14.0 (SPSS Inc., Chicago, IL, USA) was
used for statistical calculations.
Our sample consisted of 34 individuals with MDD and 37
healthy controls. Females predominated in both groups (76.5%
and 78.4%). The mean age was 37.62 ± 8.20 years in those with
MDD and 34.78 ± 6.21 years in the control group. At weeks 8-10,
mean BMI was 24.85 ± 5.18kg/m2 in the MDD group, compared
with 23.90 ± 2.76kg/m2 in the control group. In terms of age,
gender and BMI, the differences between the two groups were
not signiﬁcant (p = 0.10, p = 0.848 and p = 0.23, respectively).
At enrollment, 55.9% of the individuals with MDD were
experiencing a severe recurrent episode, 11.8% were experiencing a
moderate recurrent episode; 17.6% were experiencing a moderate
ﬁrst episode and 14.79% were experiencing a severe ﬁrst episode.
The mean HAM-D-17 score for the group was 26.65 ± 4.24 at
week 1 and 6.91 ± 3.80 at weeks 8-10.
Comparing week 1 with weeks 8-10 in terms of the postural
variables in the MDD group, we observed signiﬁcant differences
for left side pelvic position (p = 0.012), left scapular position (p =
0.046), right thoracic kyphosis (p < 0.001), left thoracic kyphosis
(p < 0.001) and sagittal head position (p < 0.001), as can be seen
in Table 1 and Figure 1.
Table 1 shows that there were signiﬁcant differences between
the MDD group at week 1 and the control group in terms of
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this was attenuated during remission.
The posterior cervical, trapezius and paraspinal muscles
counterbalance the weight of the head, and anterior head
carriage can therefore cause tenderness in the neck region.17
Using the Penha et al. methodology,16 Miranda18 found the
mean head position in a group of 37 healthy women to be
52.0 ± 6.5°. Using the same methodology, Ferreira found the
mean head position to be 47.06 ± 4.77° for a group composed
of both genders.19 These values are similar to those obtained
for our control group.
Patients presenting depressive episodes showed a marked
increase in kyphosis, which was also reduced during remission.
Kyphosis affects the muscles, reducing the ﬂexibility of anterior
thorax (intercostal) muscles, upper limb muscles originating
from the thorax (minor and major pectoralis, latissimus dorsi
and anterior serratus muscles) and cervical spine muscles (levator
scapulae and trapezius muscles).17 In the study conducted by
Miranda,18 the mean kyphosis angle was found to be 143.4 ±
7.1°, similar to that found for our control group.
right sagittal head position (p < 0.001), left sagittal head position
(p < 0.001), right thoracic kyphosis (p < 0.001) and left thoracic
kyphosis (p < 0.001), whereas, at weeks 8-10, such differences
were seen only for position of the right and left shoulders (p =
0.022 and p = 0.012, respectively).
As can be seen in Table 2, the mean BSQ score in the MDD
group was 90.03 ± 38.46 at week 1 and 75.82 ± 35.30 at weeks
8-10 (p = 0.012). In the control group, the mean BSQ score was
62.57 ± 23.04. In terms of the BSQ score, there were no signiﬁcant
differences between the MDD group at weeks 8-10 and the control
group (p = 0.127).
1. Postural variables
Although there have been studies evaluating posture in various
pathologies, few have done so in individuals with MDD, making
it difﬁcult to contextualize our results.
We found that, during episodes, patients with MDD showed
marked anterior head carriage, tend to look at the ﬂoor, and that
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379 • Revista Brasileira de Psiquiatria 2010 • vol 32 • nº 4 • dez2010
193 young adult female students of nutrition, 59.9% expressed no
dissatisfaction with their body image, and there was a signiﬁcant
association between BSQ and BMI (p = 0.026).24 In a review
of the literature on body image,25 it was concluded that current
investigations are increasingly focusing on physical appearance,
particularly body shape and weight. For men, body image is
less clear, because there have been fewer studies. For women,
dissatisfaction with body size and weight is well documented,
showing that the body image concept must be extended. Most
studies on adults evaluated student populations within a narrow
age range of 18-25 years, and those populations were typically
homogeneous in terms of race, socioeconomic status and level
Patients with MDD showed changes in body posture during
their episodic depressive exacerbation and expressed dissatisfaction
with their body image. These alterations were not ﬁnding during
the remission phase. These ﬁndings highlight the role of body
posture and body image in the expression and communication
of mood disorders and support the hypothesis that depression
is related to impairments in both emotional and physical health
This study was supported in part by the Coordenação de Aperfeiçoamento
de Pessoal de Nível Superior (CAPES, Coordination of the Advancement
of Higher Education).
In the present study, depressive patients tended to present with
pelvic retroversion, which decreased during remission. The pelvis
is the key to correct posture of the dorsal region, and the mean
pelvic inclination in normal subjects is 11 ± 4°.17 Miranda found
the mean pelvic position to be 11.3 ± 5.7° on both sides,18 again
similar to that found for our control group.
During the depressive episode, our patients showed mild
left scapular abduction, which decreased during remission. It
is known that changes in the position of the scapula adversely
affect the shoulder, predisposing to injury and chronic pain.5 In
the study conducted by Miranda,18 the mean scapular position
was 2.4 ± 0.5°, comparable to that found for our control group.18
In our study, patients with depression showed mild left scapular
abduction, which is likely related to the increased kyphosis, since
the scapula is located in the same region. There were no signiﬁcant
differences between the MDD group and the control group in
terms of the other postural variables.
We found that, during episodes, there are measurable changes
in the posture of individuals with MDD. Such changes included
signiﬁcant increases in head ﬂexion, thoracic kyphosis, a trend
toward pelvic retroversion and an increase in scapular distance,
all of which interfere with the proper functioning of the skeletal
muscles. During remission, these aspects improved (Figure 1).
Such alterations, in addition to having consequences such as pain,
tension and shortness of breath, are often part of the spectrum
of symptoms observed in MDD, characterizing a “depressive
2. Body image
During depressive episodes, the patients in the MDD group
were mildly dissatisﬁed with their body image, and this was
primarily attributable to sadness and discouragement. During
remission, there was no apparent dissatisfaction with body image,
probably due to a lessening of the depressive symptoms. Control
subjects did not express any dissatisfaction with their body image.
Therefore, in this aspect, the controls were no different than the
patients during remission. Several studies have associated poor
body image with eating disorders and depressive symptoms.20,21
One such study evaluated patients with class III obesity, analyzing
periodic episodes of compulsive eating, anxiety, depression and
body image distortion.21 In that study, all of the participants
were found to have depressive symptoms, and 76% expressed
concerns regarding body image. In our study, care was taken to
study only patients with a speciﬁc diagnosis of MDD, rather
than all patients with depressive symptoms, which increases the
relevance of our ﬁndings.
In a study involving a sample of the young adult female
population of Sweden, the mean BSQ score was 74.50 ± 29.50,
similar to that found for our controls.22 A study conducted in
Brazil showed that, in a group of 582 female and male university
employees, most (90.2%) expressed no dissatisfaction with their
body image, the mean BSQ score being 65.06 ± 31.66,23 which is
also in agreement with our ﬁndings. In another study evaluating
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Revista Brasileira de Psiquiatria 2010 • vol 32 • nº 4 • dez2010 • 380
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