Accept, distract, or reframe? An exploratory experimental comparison of strategies for coping with intrusive body image thoughts in anorexia nervosa and body dysmorphic disorder

Web-Based Therapist-Guided Mindfulness-Based Cognitive Behavioral Therapy for Body Dysmorphic Disorder: Pilot Randomized Controlled Trial

BACKGROUND

Internet-based cognitive behavioral therapy (CBT) and stand-alone mindfulness meditation interventions are gaining empirical support for a wide variety of mental health conditions. In this study, we test the efficacy of web-based therapist-guided mindfulness-based cognitive behavioral therapy (CBT-M) for body dysmorphic disorder (BDD), a psychiatric disorder characterized by preoccupations with perceived defects in appearance.

OBJECTIVE

This study aims to determine whether CBT-M for BDD delivered on the web is feasible and acceptable and whether mindfulness meditation adds to CBT treatment effects for BDD.

METHODS

In this 8-week, 2-arm, parallel pilot randomized controlled trial, n=28 adults (aged between 18 and 55 years) were randomly allocated to an experimental group (web-based therapist-guided CBT-M) or a control group (web-based therapist-guided CBT). Study retention, accrual, and intervention adherence were assessed, along with self-report measures for BDD, depression, anxiety, and pain intensity taken at baseline and postintervention.

RESULTS

This study was feasible to implement and deemed acceptable by participants. After 8 weeks, significant improvements were found on all outcome measures for both treatment groups, and large between-group effect sizes favoring CBT-M were found for BDD symptom severity (d=-0.96), depression (d=-1.06), pain severity (d=-1.12), and pain interference (d=-1.28). However, linear mixed models demonstrated no significant differences between the groups over 8 weeks.

CONCLUSIONS

The results suggest that mindfulness meditation may add to beneficial web-based CBT treatment effects for BDD. An adequately powered randomized control trial of web-based CBT-M is warranted.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05402475, http://clinicaltrials.gov/ct2/show/NCT05402475.

A smartphone app for the prevention and early intervention of body dysmorphic disorder: Development and evaluation of the content, usability, and aesthetics

Body dysmorphic disorder (BDD) is an impairing condition characterized by excessive appearance concerns that frequently begin in adolescence, thus making this phase an eminent target for prevention and early intervention. We developed a cognitive-behavioral app-based program (AINA) intended for prevention and early intervention of BDD. As part of the iterative development process, perceptions of usability, aesthetics, and content were investigated. A sample of 38 adolescents and young adults aged between 14 and 21 years tested the app in a laboratory setting and completed a survey of diagnostic and user experience questionnaires. Overall, usability, aesthetics, and content of the app received positive evaluations. Regression analyses did not point to any large effects of age, gender, years of education, self-esteem, or BDD symptom severity on user evaluations. On average, participants had no concerns about privacy or data security of the app, indicating that these aspects will presumably not act as barriers to usage. Altogether, the present results are encouraging. Future research needs to examine whether AINA is an efficacious measure for prevention and early intervention of BDD.

Dissociation and Suicidality in Eating Disorders: The Mediating Function of Body Image Disturbances, and the Moderating Role of Depression and Anxiety

In patients with eating disorders (EDs), elevated dissociation may increase the risk of suicide. Bodily related disturbances, depression, and anxiety may intervene in the association between dissociation and suicidality. In this study we aimed to examine the influence of bodily related disturbances, depression, anxiety, severity of ED symptoms, body mass index (BMI), and type and duration of the ED on the relationship between elevated dissociation and elevated suicidality. The study included 172 inpatients: 65 with anorexia nervosa restricting type, 60 with anorexia nervosa binge/purge type, and 37 with bulimia nervosa. Participants were assessed using self-rating questionnaires for dissociation, suicidality, bodily related parameters, and severity of ED symptomatology, depression, and anxiety. We found that dissociation and suicidality were directly associated. In addition, depression and anxiety moderated the mediating role of body image parameters in the association between increased dissociation and increased suicidality. Thus, only in inpatients with high depression and anxiety, i.e., above the median range, body image disturbances were found to mediate the association between dissociation and suicidality. ED-related parameters did not moderate these relationships. Our study demonstrates that in inpatients with EDs, increased dissociation may be significantly associated with increased suicidality, both directly and via the intervening influence of body image, depression, and anxiety.

Direct comparisons of anorexia nervosa and body dysmorphic disorder: A systematic review

Anorexia nervosa (AN) and body dysmorphic disorder (BDD) are serious psychiatric conditions, both of which are associated with a disturbance of body image. The aim of this paper was to review those studies that have directly compared groups of individuals with AN and BDD, to determine similarities and differences in presentation between the two conditions. The literature was searched to September 2018, and studies were included if they were English language, empirical research papers published in peer-reviewed journals, specifically comparing AN and BDD patients. Fifteen relevant studies were identified. The results suggested that individuals with AN and BDD share a number of similarities, including their degree of body dissatisfaction. Differences between the conditions included primary concerns with body shape and weight in AN, and much more diffuse concerns (but predominantly the face) in BDD. The small number of studies, along with the limited replication of results emphasises the need for greater research in this area. However, the studies undertaken to date highlight the high degree of overlap between AN and BDD and suggests that the conditions may represent similar body image disorders. This has implications for the nosological status of AN and BDD.

Escalation from normal appearance related intrusive cognitions to clinical preoccupations in Body Dysmorphic Disorder: A cross-sectional study

Current cognitive approaches to Body Dysmorphic Disorder (BDD) assume that appearance-related intrusive cognitions and their functional consequences characterize the disorder, in a similar way that obsessive intrusive thoughts characterize the Obsessive-Compulsive Disorder (OCD). This study explores whether normal but unwanted appearance-related intrusive thoughts (AITs), escalate to clinical AITs when they are dysfunctionally appraised and instigate counterproductive neutralizing strategies. From a sample of 344 non-clinical individuals who reported a highly upsetting AIT during the past three months two subgroups were extracted according to their high (n = 68) and low (n = 276) vulnerability to BDD. The subjects in the high-risk group obtained significantly higher scores on the frequency of the most disturbing AIT and its emotional impact, interference, and appraisals evaluated with the Appearance Intrusions Questionnaire (AIQ). Additionally, two subgroups of 15 subjects each, with high and low risk to BDD, were formed and their scores were compared to 10 patients with BDD. The AIT had a greater emotional negative impact and more severe consequences on individuals with BDD compared to individuals at high-risk of BDD, which in turn, reported worse consequences of the AIT than those at low-risk. These results empirically support the similarities between BDD and OCD regarding their functional and phenomenological characteristics.

Advances in the treatment of anorexia nervosa: a review of established and emerging interventions

BACKGROUND

Anorexia nervosa (AN) is a disabling, deadly and costly mental disorder. Until recently, treatment recommendations were based on expert opinion and limited evidence. The aim of this systematic review is to synthesise recent evidence on established and emerging AN treatments and to forecast trends for future developments.

METHODS

We systematically review trials of established treatments and associated process outcome studies from the last 5 years, published since a previous review in this journal. 'Established' treatments were those that are widely used in AN, recommended by guidelines and/or have been tested in at least one large randomised controlled trial. Secondly, we summarise emerging treatments for AN, i.e. those that have only been (or are currently being) tested in proof-of concept, feasibility or pilot trials.

RESULTS

We identified 19 published trials of established treatments (15 of high or moderate quality), mostly assessing psychological therapies (n = 17). We also found 11 published trials of emerging treatments, and a total of 34 registered, as yet unpublished trials. Promising emerging treatments include cognitive remediation therapy, exposure therapy and non-invasive neuromodulation.

CONCLUSIONS

Evidence generation on the treatment of AN has dramatically accelerated, with our understanding of the role of family-based approaches for adolescents more nuanced and a range of psychological approaches available for the treatment of adults. Evidence on emerging treatments and from forthcoming trials suggests that there is a shift towards more targeted brain-based interventions. Future studies need to focus on elucidating mechanisms of action of treatments and what works best for whom.

Mindfulness in Anorexia Nervosa: An Integrated Review of the Literature

BACKGROUND

Anorexia nervosa is a serious psychiatric illness with limited evidenced-based treatment options. Mindfulness appears useful in many conditions, but few studies focus on its use in individuals with anorexia nervosa.

OBJECTIVE

To examine and summarize studies of mindfulness in individuals with anorexia nervosa and identify areas for future research.

DESIGN

An integrated review was conducted by searching health care computerized databases.

RESULTS

Results were mixed among the eight studies that met inclusion criteria. Multimodal mindfulness-based therapies appear effective, while brief interventions may be equally useful or result in greater anxiety compared to distraction. Qualitative data support that some participants feel mindfulness is challenging but beneficial.

CONCLUSION

Mindfulness as a concurrent part of therapy and/or when routinely practiced may be more clinically useful than single-episode mindful eating interventions. Due to the complexity of the concept of mindfulness and limited existing data, additional research is needed.

Body representation disturbances in visual perception and affordance perception persist in eating disorder patients after completing treatment

Body image disturbances (BID) are a key feature of eating disorders (ED). Clinical experience shows that BID exists in patients who Completed their Eating Disorder Treatment (CEDT), however studies concerning BID in CEDT patients are often limited to cognition and affect, measured by interviews and questionnaires. The current study is the first systematic study investigating the full scope of the mental body representation, including bodily attitudes, visual perception of body size, tactile perception, and affordance perception in CEDT patients. ED patients (N = 22), CEDT patients (N = 39) and healthy controls (HC; N = 30) were compared on BID tasks including the Body Attitude Test (BAT), Visual Size Estimation (VSE), Tactile Estimation Task (TET), and Hoop Task (HT). Results on the BAT show higher scores for ED patients compared to CEDT patients and HC but no difference between CEDT patients and HC. Both ED and CEDT patients show larger overestimations on the VSE and HT compared to HC, where ED patients show the largest overestimations. No group differences were found on the TET. The results indicate the existence of disturbances in visual perception and affordance perception in CEDT patients. Research focussing on more effective treatments for ED addressing multiple (sensory) modalities is advised.

"It runs in my family …": The association of perceived family history with body dissatisfaction and weight bias internalization among overweight women

Aspects of poor body acceptance (BA), such as internalized weight bias and dissatisfaction with one's shape and size, are the strongest predictors of disordered eating and are associated with reduced engagement in healthy behaviors. Perceiving oneself as having a family history of overweight (PFH) could boost BA by increasing attributions for inherited, biological causes of weight. A community sample of 289 women who were overweight from the Washington, DC metropolitan area who were dissatisfied with their current weight (68% Black; 32% White) enrolled in this study in 2012. PFH of overweight was associated with decreased internalized weight bias among white women and marginally increased body shape satisfaction generally. The relationship between PFH and BA was not explained by biological attributions for weight. Perceptions that overweight runs in one's family can be protective with respect to BA. This is suggestive of the potential benefit of integrating family-based approaches into weight management interventions.

ARTÍCULO DE REVISIÓN: GENERALIDADES DE LA IMAGEN CORPORAL/ REVIEW ARTICLE: OVERVIEW OF THE BODY IMAGE

<p><strong>RESUMEN</strong></p><p><strong>Introducción:</strong> La imagen corporal es la representación del cuerpo que cada individuo construye en su mente. Ésta contempla dos componentes: imagen corporal propiamente dicha y esquema corporal, caracterizados por ser una representación consiente e inconsciente del cuerpo respectivamente y son influenciados a partir de la interacción de los individuos con su entorno. <strong>Objetivo:</strong> El presente documento hace parte del marco teórico del estudio “Imagen corporal en futbolistas”, y contempla una revisión de las generalidades de la imagen corporal en relación a su construcción y desarrollo, sus componentes, dimensiones y los efectos que tiene sobre la práctica deportiva. <strong>Materiales y métodos:</strong> Se realizó una búsqueda en las bases de datos Pubmed, Scielo, Science Direct y Google académico entre los años 1996 y 2014 introduciendo los términos “Imagen corporal en deporte”, “modelo interno en control motor”, “evaluación de imagen corporal”, “esquema corporal”. <strong>Conclusiones: </strong>La imagen corporal  posee un comportamiento dinámico gracias al cual se construye y  modifica a lo largo de la vida a partir de los estímulos sensoriales en términos de cuerpo y espacio, además de estímulos socioculturales que impactan directamente en la autoestima y rendimiento deportivo. El desarrollo  de programas de actividad físico-deportiva generan un impacto positivo sobre la imagen corporal en todas las edades siempre y cuando se tengan presentes parámetros específicos de entrenamiento. En cuanto al esquema corporal estos programas favorecen el mejoramiento de funciones cognitivas, la adquisición y modificación de modelos internos que además son nutridos por estímulos sensoriales propios del entorno deportivo. </p>

Anorexia nervosa and body dysmorphic disorder: A comparison of body image concerns and explicit and implicit attractiveness beliefs

Although body image is central to the etiological models of anorexia nervosa and body dysmorphic disorder, studies comparing body image and beliefs about attractiveness between the disorders are rare. Sixty-nine individuals (anorexia nervosa: n=24, body dysmorphic disorder: n=23, healthy controls: n=22) completed self-report measures (body image and general psychopathology), diagnostic interviews, and Go/No-Go Association tasks measuring implicit associations. Compared to controls, both clinical groups exhibited greater negative body image, a more negative attitude toward their physical selves, and more dysfunctional coping strategies (ps<.001). Also, both clinical groups shared greater explicit beliefs about the importance of attractiveness (ps<.001). In addition to supporting previous research with regard to comparable body image disturbance, this study also showed that beliefs regarding the importance of appearance (e.g., "one must be attractive to be successful") might be a fruitful target for therapy across both disorders.