Seeing "changes" that aren't there: facial and object discrimination in body dysmorphic disorder

Visual Perceptual Processing Abnormalities in Body Dysmorphic Disorder

Phenomenological observations of individuals with body dysmorphic disorder (BDD), coupled with evidence from neuropsychological, psychophysical, and neuroimaging studies, support a model of aberrant visual perception characterized by deficient global/holistic, enhanced detail/local processing, and selective visual-attentional biases. These features may contribute to the core symptomatology of distorted perception of their appearance, in addition to misinterpretation of others' facial expressions and poor insight regarding their misperceived appearance defects. Insights from visual processing studies can contribute to the development of novel interventions, such as perceptual retraining and non-invasive neuromodulation. However, much remains to be understood about visual perception in BDD. Future research should leverage brain imaging modalities with high temporal resolutions and employ study designs that induce conflicts in multisensory integration, thereby advancing our mechanistic understanding of distorted visual perception observed in BDD.

Multidimensional Perfectionism and Facial Symmetry, Attractiveness and Approachability: Comparing Those With High Versus Low Dysmorphic Concerns

Concerns pertaining to one's physical appearance or specific body parts is not uncommon in the community. Whether such dissatisfaction is related to superior (or inferior) face perception abilities, or interacts with related constructs, such as perfectionism, is unknown. The current study aimed to investigate whether multidimensional perfectionism (e.g. involving concern over mistakes or doubts over actions) and facial ratings differed in those with high versus low dysmorphic concerns (i.e. excessive preoccupation about perceived physical flaws). Respondents (N = 343) from the community took part in an online study, comprising questionnaires assessing dysmorphic concerns and perfectionism. They also completed a face perception task involving symmetry, attractiveness and approachability ratings for a series of faces, some of which had been digitally manipulated to yield differing degrees of symmetry. Respondents were divided into those with high (n = 147) versus low (n = 196) dysmorphic concerns. Group comparisons using analyses of variance were conducted. Those with high dysmorphic concerns exhibited significantly elevated overall perfectionism (as well as on facets involving concern over mistakes, personal standards, parental perceptions and doubts over actions). No significant group differences were uncovered for the face perception task, involving ratings of symmetry, attractiveness and approachability. Perfectionism differences existed in a non-clinical sample with high dysmorphic concerns, though further work is needed to elucidate consistent patterns regarding perfectionism facets. More research examining face perception deficits on the clinical end of the body image spectrum, such as in those with body dysmorphic disorder, as well as utilising alternate task versions involving self-referential stimuli, are recommended.

Is poor global processing a transdiagnostic feature of Body Dysmorphic Disorder and Anorexia Nervosa? A meta-analysis

Body dysmorphic disorder (BDD) and anorexia nervosa (AN) are characterised by body image disturbance. It has been suggested that poor global integration in visual processing may underlie distorted body image, but empirical studies have yielded mixed results. The current study involved two meta-analyses aimed at examining the extent to which poor global processing is evident in BDD and AN. Studies were identified through a systematic literature search up to October 2020. The BDD search yielded 16 studies and the AN search yielded 18 studies. Random-effect models demonstrated a small pooled effect size for BDD (g = -0.44, 95 % CI -0.70, -0.17, p < 0.001) and a moderate pooled effect size for AN (g = -0.63, 95 % CI -0.77, -0.49, p <  .001), with no evidence of significant publication bias for either. The results provide evidence that poor global processing is a transdiagnostic feature of both BDD and AN, although effects may be more pronounced in AN. Our findings highlight the possibility that interventions aimed at promoting global visual processing could prove beneficial in disorders characterised by distorted body image.

Neural Correlates of Own- and Other-Face Perception in Body Dysmorphic Disorder

BACKGROUND

Body dysmorphic disorder (BDD) is characterized by an excessive preoccupation with one or more perceived flaws in one's own appearance. Previous studies provided evidence for deficits in configural and holistic processing in BDD. Preliminary evidence suggests abnormalities at an early stage of visual processing. The present study is the first examining early neurocognitive perception of the own face in BDD by using electroencephalography (EEG). We investigated the face inversion effect, in which inverted (upside-down) faces are disproportionately poorly processed compared to upright faces. This effect reflects a disruption of configural and holistic processing, and in consequence a preponderance of featural face processing.

METHODS

We recorded face-sensitive event-related potentials (ERPs) in 16 BDD patients and 16 healthy controls, all unmedicated. Participants viewed upright and inverted (upside-down) images of their own face and an unfamiliar other face, each in two facial emotional expressions (neutral vs. smiling). We calculated the early ERP components P100, N170, P200, N250, and the late positive component (LPC), and compared amplitudes among both groups.

RESULTS

In the early P100, no face inversion effects were found in both groups. In the N170, both groups exhibited the common face inversion effects, with significantly larger N170 amplitudes for inverted than upright faces. In the P200, both groups exhibited larger inversion effects to other (relative to own) faces, with larger P200 amplitudes for other upright than inverted faces. In the N250, no significant group differences were found in face processing. In the LPC, both groups exhibited larger inversion effects to other (relative to own) faces, with larger LPC amplitudes for other inverted than upright faces. These overall patterns appeared to be comparable for both groups. Smaller inversion effects to own (relative to other) faces were observed in none of these components in BDD, relative to controls.

CONCLUSIONS

The findings suggest no evidence for abnormalities at all levels of early face processing in our observed sample of BDD patients. Further research should investigate the neural substrates underlying BDD symptomatology.

A systematic review and meta-analysis of cognitive processing deficits associated with body dysmorphic disorder

This systematic review and meta-analysis examined the evidence supporting the association between body dysmorphic disorder (BDD) symptomology and four types of cognitive processing abnormalities: local processing, selective attention, interpretive biases, and memory deficits. Twenty-three studies met inclusion requirements that examined differences in performance on cognitive tasks between BDD and control groups across the four categories. Multilevel modelling was used to calculate an overall effect size for each cognitive category. BDD and control groups differed significantly on measures of selective attention (g = 0.60, 95% CI = 0.26: 0.93), interpretive biases (g = 0.30, 95% CI = . 07: 0.54), and memory deficits (g=.56, 95% CI = 0.26: 0.87). Differences between the BDD and control groups on measures of local processing did not reach significance. These findings support the hypothesis that people with BDD may selectively attend to perceived threats or to disorder-related stimuli, misinterpret ambiguous stimuli as threatening, overvalue the importance of attractiveness, and have inaccurate coding and recall for facial or bodily stimuli. Recommendations for future research of these specific cognitive deficits in BDD include introducing the use of Modified Dot Probe Paradigms and new treatment targets that can be used as adjuncts to current treatment modalities.

A systematic review of visual processing and associated treatments in body dysmorphic disorder

OBJECTIVE

Recent advances in body dysmorphic disorder (BDD) have explored abnormal visual processing, yet it is unclear how this relates to treatment. The aim of this study was to summarize our current understanding of visual processing in BDD and review associated treatments.

METHOD

The literature was collected through PsycInfo and PubMed. Visual processing articles were included if written in English after 1970, had a specific BDD group compared to healthy controls and were not case studies. Due to the lack of research regarding treatments associated with visual processing, case studies were included.

RESULTS

A number of visual processing abnormalities are present in BDD, including face recognition, emotion identification, aesthetics, object recognition and gestalt processing. Differences to healthy controls include a dominance of detailed local processing over global processing and associated changes in brain activation in visual regions. Perceptual mirror retraining and some forms of self-exposure have demonstrated improved treatment outcomes, but have not been examined in isolation from broader treatments.

CONCLUSION

Despite these abnormalities in perception, particularly concerning face and emotion recognition, few BDD treatments attempt to specifically remediate this. The development of a novel visual training programme which addresses these widespread abnormalities may provide an effective treatment modality.

Altering Visual Perception Abnormalities: A Marker for Body Image Concern

The body image concern (BIC) continuum ranges from a healthy and positive body image, to clinical diagnoses of abnormal body image, like body dysmorphic disorder (BDD). BDD and non-clinical, yet high-BIC participants have demonstrated a local visual processing bias, characterised by reduced inversion effects. To examine whether this bias is a potential marker of BDD, the visual processing of individuals across the entire BIC continuum was examined. Dysmorphic Concern Questionnaire (DCQ; quantified BIC) scores were expected to correlate with higher discrimination accuracy and faster reaction times of inverted stimuli, indicating reduced inversion effects (occurring due to increased local visual processing). Additionally, an induced global or local processing bias via Navon stimulus presentation was expected to alter these associations. Seventy-four participants completed the DCQ and upright-inverted face and body stimulus discrimination task. Moderate positive associations were revealed between DCQ scores and accuracy rates for inverted face and body stimuli, indicating a graded local bias accompanying increases in BIC. This relationship supports a local processing bias as a marker for BDD, which has significant assessment implications. Furthermore, a moderate negative relationship was found between DCQ score and inverted face accuracy after inducing global processing, indicating the processing bias can temporarily be reversed in high BIC individuals. Navon stimuli were successfully able to alter the visual processing of individuals across the BIC continuum, which has important implications for treating BDD.

Facial discrimination in body dysmorphic, obsessive-compulsive and social anxiety disorders

Body dysmorphic disorder (BDD) is characterized by preoccupation with perceived flaws in one's own appearance. Several risk factors such as aesthetic perceptual sensitivity have been proposed to explain BDD's unique symptomatology. Although research on facial discrimination is limited so far, the few existing studies have produced mixed results. Thus, the purpose of this study was to further examine facial discrimination in BDD. We administered a facial discrimination paradigm, which allows to assess the ability to identify slight to strong facial changes (e.g., hair loss, acne) when presented with an original (unmodified) facial image, relative to a changed (modified) facial image. The experiment was administered in individuals with BDD, social anxiety disorder, obsessive-compulsive disorder, and mentally healthy controls (32 per group, respectively). Overall, groups did not differ with respect to their ability to correctly identify facial aberrations when presented with other people's faces. Our findings do not support the hypothesis of enhanced general aesthetic perceptual sensitivity in individuals with (vs. without) BDD.

Facial affect recognition in body dysmorphic disorder versus obsessive-compulsive disorder: An eye-tracking study

BACKGROUND

Body dysmorphic disorder (BDD) is characterised by repetitive behaviours and/or mental acts occurring in response to preoccupations with perceived defects or flaws in physical appearance (American Psychiatric Association, 2013). This study aimed to investigate facial affect recognition in BDD using an integrated eye-tracking paradigm.

METHOD

Participants were 21 BDD patients, 19 obsessive-compulsive disorder (OCD) patients and 21 healthy controls (HC), who were age-, sex-, and IQ-matched. Stimuli were from the Pictures of Facial Affect (Ekman & Friesen, 1975), and outcome measures were affect recognition accuracy as well as spatial and temporal scanpath parameters.

RESULTS

Relative to OCD and HC groups, BDD patients demonstrated significantly poorer facial affect perception and an angry recognition bias. An atypical scanning strategy encompassing significantly more blinks, fewer fixations of extended mean durations, higher mean saccade amplitudes, and less visual attention devoted to salient facial features was found.

CONCLUSIONS

Patients with BDD were substantially impaired in the scanning of faces, and unable to extract affect-related information, likely indicating deficits in basic perceptual operations.

Clinical Features, Cognitive Biases, and Treatment of Body Dysmorphic Disorder

In the past two decades, research advances have enhanced our understanding of the clinical features, cognitive biases, and treatment of body dysmorphic disorder (BDD). In this review, we critically examine the current state of the evidence on the proposed cognitive and emotional processing mechanisms of BDD. We describe how major findings in these areas made unique contributions to the development of an empirically informed cognitive-behavioral model of BDD, which in turn facilitated the translation of research to treatment strategies. Finally, we outline important areas of future research.