Perceptual and cognitive biases in individuals with body dysmorphic disorder symptoms

Appearance-related safety behaviors predict symptoms of body dysmorphic disorder following internet-based treatment

Recent experimental evidence has found that appearance related safety behaviors (i.e., practices meant to avoid a perceived feared outcome) likely play a crucial role in maintaining symptoms of body dysmorphic disorder (BDD). The present study sought to determine if these behaviors predicted BDD symptom severity following treatment. Participants (N = 50) with BDD were randomized to either eight sessions of interpretation bias modification or progressive muscle relaxation. Both treatments led to reductions in BDD symptom severity and appearance-related safety behaviors, though moderate levels of safety behaviors persisted at both posttreatment and follow-up. Importantly, post-treatment appearance related safety behaviors significantly predicted BDD symptom severity at three-month follow-up. Taken together, the present findings suggest appearance related safety behaviors maintain BDD symptoms following effective computerized treatments and provide further evidence for their importance in the treatment of BDD.

Negative comments and social media: How cognitive biases relate to body image concerns

Body image concern (BIC) is a prevalent issue thought to be exacerbated by social media. In addition to sociocultural factors, cognitive biases may also contribute to BIC. We explore whether cognitive biases in memory for body image-related words, presented in a mock social-media context, are associated with BIC in young adult women. A sample of 150 University students was presented with a series of body image-related comments aimed at either themselves, a close friend, or a celebrity in a recognisable social media context. Afterwards, a surprise memory task was completed that assessed the participant's memory for body image-related words (item memory), their insight (metamemory), and to whom a specific word was directed (source memory). Self-referential biases were identified for both item memory and source memory. Individuals with greater BIC displayed a greater self-referential bias for correctly and incorrectly sourcing negative words to themselves compared with both friend and celebrity. A greater self-referential effect in metacognitive sensitivity was also associated with higher BIC. We provide novel evidence for a cognitive bias in sourcing negative body image-related information to the self in individuals with higher BIC. The results should inform cognitive remediation programmes aimed at treating individuals with body and eating-related disorders.

A self-report assessment of appearance-related safety behaviours: Development and psychometric properties

BACKGROUND

Individuals with appearance concerns may engage in maladaptive appearance-related safety behaviours aimed at checking, hiding or fixing perceived flaws in their appearance.

AIMS

This investigation examined the psychometric properties of a newly developed measure of appearance-related safety behaviours across three different studies.

METHOD

The first two studies utilized exploratory and confirmatory factor analysis, respectively, to understand the factor structure of the measure. The final version of the Appearance-Related Safety Behavior Scale (ARSB) consisted of 13 items and two subscales related to behavioural avoidance and appearance maintenance.

RESULTS

Number of appearance-related safety behaviours was positively associated with body dysmorphic disorder symptomology and functional impairment, as well as social anxiety and eating disorder symptoms. The measure also demonstrated convergent validity with other appearance-related measures. Scores on the ARSB also predicted performance on an appearance-related behavioural task (time spent fixing appearance prior to having a picture taken). The third study found that scores on the ARSB were higher in a body dysmorphic disorder sample compared with healthy controls. Furthermore, change in scores on the ARSB was correlated with change in body dysmorphic disorder symptoms and impairment in a treatment study for body dysmorphic disorder.

CONCLUSIONS

Clinical implications and potential uses of the measure as a clinical and research tool are discussed.

The role of biases in the judgement processing of (un)attractive faces in body dysmorphic symptomatology

The current study tested the novel hypothesis that elevated facial appearance concern reflects a heightened tendency to judge facial appearance in terms of attractiveness, rather than in terms of attractiveness-irrelevant dimensions. Seventy-three females, reporting either high or low facial appearance concerns, were exposed to an individualised stimulus development protocol which involved a photoshoot and the subsequent selection of photographs perceived to be most and least attractive. Participants were then required to judge photographs in terms of either attractiveness or the eye gaze direction of the individual in the photograph. Results revealed that when judging attractiveness, low facial concern participants were faster to classify photographs as belonging to the attractive category rather than the unattractive category. We termed this potentially protective bias the General Attractiveness Recognition Advantage. Moreover, regardless of judgement required, high facial concern participants were faster to make responses to unattractive relative to attractive photographs of themselves. We termed this potential vulnerability bias the Efficient Processing of Unattractive Self. Further analyses revealed that the former bias associated with broader body dysmorphic symptomatology. The current findings, although inconsistent with the hypothesis under test, were novel in revealing two distinct mechanisms which distinguished high and low facial appearance concern individuals.

Prevalence of Body Dysmorphic Disorder and Predictors of Body Image Disturbance in Adolescence

Background:

Body dysmorphic disorder encompasses a range of cognitive and behavioural states stemming from distressing, negative evaluations of one’s appearance. Despite the seriousness of this condition, little is known about who is likely to receive a diagnosis and more importantly what the putative risk factors are. This is particularly so among adolescent samples, where the extant literature is considerably smaller.

Objective:

This study had two broad aims: to estimate the prevalence of body dysmorphic disorder within a young-adult population, and to examine the predictors of body image disturbance.

Methods:

Three-hundred and four adolescents (242 females; Mage = 17.68) completed the Body Image Disturbance Questionnaire and Body Dysmorphic Disorder Questionnaire, along with measures of clinical psychopathology, self-esteem, experiences of parenting, and bullying.

Results:

Body dysmorphic disorder was present in 3.9% of the sample, which is in line with previous estimates among adolescents. More interestingly, results indicated that instances of high stress, low self-esteem, and reported experiences of bullying were able to predict 48% of body image dissatisfaction.

Conclusions:

Psychological interventions should be directed towards adolescents with body image concerns, especially if they also report bullying, elevated stress, or diminished selfesteem. However, additional research is still warranted to gain an increasingly accurate understanding of the prevalence of body dysmorphic disorder and who is susceptible to developing this disorder and how we can best serve these individuals in the community.

Biased distance estimation in social anxiety disorder: A new avenue for understanding avoidance behavior

OBJECTIVES

People regulate their interpersonal space appropriately to obtain a comfortable distance for interacting with others. Socially anxious individuals are especially prone to discomfort from and fear of physical closeness, leading them to prefer a greater interpersonal distance from others. Previous studies also indicate that fear can enhance the threat-related elements of a threatening stimulus. For example, spider phobia is associated with estimating spiders as bigger and faster than they actually are. Nonetheless, it is still unclear whether the preference of those with social anxiety disorder (SAD) to maintain greater distance from others is associated with biased estimations of interpersonal distance.

MATERIALS AND METHODS

A total of 87 participants (44 clinically diagnosed with SAD and 43 control) performed validated computerized and ecological tasks in a real-life setting while social space estimations and preferences were measured.

RESULTS

Participants with SAD felt comfortable when maintaining a greater distance from unfamiliar others compared to the control group and estimated unfamiliar others to be closer to them than they actually were. Moreover, the estimation bias predicted their preferred distance from strangers, indicating a strong association between estimation bias severity and actual approach-avoidance behavior.

CONCLUSION

Our findings indicate that distance estimation bias underlies avoidance behavior in SAD, suggesting the involvement of a new cognitive mechanism in personal space regulation.

A Multimethod Analysis of Incompleteness and Visual "Not Just Right" Experiences in Body Dysmorphic Disorder

Individuals with body dysmorphic disorder (BDD) often report engaging in repetitive behaviors aimed at reducing feelings of imperfection anchored to their appearance. "Not just right" experiences (NJREs) and incompleteness (INC) are constructs related to perfectionism that have traditionally been studied in obsessive-compulsive disorder, though recent research has also linked these phenomena to BDD. We sought to replicate and extend this research via two studies. Study 1 examined BDD symptoms, INC, as well as harm avoidance (HA) in an unselected sample (N = 179); moderate associations were observed between symptoms and both INC and HA. Participants also completed a novel visual NJRE task in which they were shown appearance-related and non-appearance-related images meant to evoke an NJRE response (i.e., discomfort and urge to "fix" stimuli). BDD symptoms predicted reactivity to appearance-related NJRE stimuli above negative affect. Study 2 compared INC, HA, and task reactivity in a BDD sample (N = 50) to nonpsychiatric controls (N = 44). The BDD group evidenced greater INC, HA, and reactivity to both appearance and nonappearance NJRE stimuli, relative to controls; however, group differences did not remain after controlling for age and negative affect. These studies broadly corroborate previous research highlighting NJREs and INC as potential vulnerability factors relevant to BDD, though these phenomena may not be specific to BDD symptoms.

Intranasal oxytocin modulates higher order social cognition in body dysmorphic disorder

BACKGROUND

Body dysmorphic disorder (BDD) is a psychiatric disorder with specific impairments in social cognition related to excessive concerns about one's appearance. Individuals with BDD have difficulty identifying emotional expressions and attribute internal factors for others' emotional expressions in self-referent (but not other-referent) scenarios. Given the role of oxytocin in regulating social approach behavior and social salience, we hypothesized that oxytocin would improve biases in emotion recognition, attributions, and threat interpretations in individuals with BDD, compared to healthy controls (HCs). This is the first study to examine the effects of oxytocin in people with BDD.

METHODS

Eighteen participants with BDD and 16 HCs received a single dose of 24 international units of intranasal oxytocin (Syntocinon®) or matching placebo in a randomized, placebo-controlled, within-subject crossover design. Participants completed the Emotion Recognition Task and Interpretation Questionnaire 45 min after administration.

RESULTS

Oxytocin, relative to placebo, did not improve emotion recognition accuracy in either self-referent or other-referent contexts for individuals with BDD. However, oxytocin led to greater internal attributions in other-referent contexts for those with BDD compared to HCs. Rather than reducing self-blame, oxytocin led to other-directed blame. Oxytocin did not impact threat interpretations in BDD.

CONCLUSIONS

Oxytocin may only impact specific aspects of higher order social cognition in BDD and may have unwanted effects on emotion attributions. Our results caution its clinical use in BDD.

Effects of induced appearance-related interpretation bias: A test of the cognitive-behavioral model of body dysmorphic disorder

BACKGROUND AND OBJECTIVES

Interpretation biases are hypothesized to maintain body dysmorphic disorder (BDD). Although their existence and malleability have been investigated in clinical studies, their causal status in the maintenance of BDD remains unclear. This study examined the effects of a single-session appearance-related interpretation bias training (CBM-I) on bias indices and stress reactivity (i.e., distress, appearance dissatisfaction, self-esteem, perceived physical attractiveness), exploring the causality predicted in cognitive-behavioral models.

METHODS

We used a modified version of the Word Sentence Association Paradigm (WSAP), assessing explicit (i.e., decision rates) and more implicit interpretation bias components (i.e., reaction times). Mentally healthy students (N = 112) were randomized to training conditions enhancing positive interpretation patterns (PT) vs. negative interpretation patterns (NT) vs. a no-feedback control condition (CC). Stress reactivity was assessed during the Cyberball Paradigm.

RESULTS

The PT showed a pre-post increase in adaptive bias patterns regarding decision and a differential pre-post decrease in reaction times for the rejection of negative interpretations, compared to the other groups. There were no condition-congruent post-training differences in stress reactivity. However, residual interpretation bias change was significantly correlated with state distress, self-esteem and appearance dissatisfaction during stressor exposure.

LIMITATIONS

Limitations pertaining to sample characteristics, training and assessment overlap, and stressor task design are discussed.

CONCLUSIONS

Findings suggest that appearance-related interpretation bias is modifiable both explicitly and more implicitly via CBM-I in a mentally healthy sample. The causal status of interpretation bias in BDD maintenance warrants further investigation.

I feel bad and look worse than you: Social comparisons moderate the effect of mood on face health judgement

Mood can bias the judgements people make about themselves and how people compare themselves to others. However, it is not yet clear whether mood also affects appearance-based self-evaluations and social comparisons. Given the importance of perceived health status for well-being, we investigated the effect of mood on self-image and social comparisons of healthiness during two versions of a face health judgement task. Thirty participants judged how they felt compared to healthy and unhealthy looking versions of their own (self version) and a stranger's face (stranger version), after a positive, negative and neutral mood induction. The effect of mood was dependent on self/stranger task order. Although mood did not affect face health judgement for participants who initially judged themselves against their own face, it did affect face health judgement for participants who initially judged themselves in comparison to a stranger's face. After the positive and negative mood inductions, these participants judged themselves as equivalent to healthier/unhealthier looking versions of their own and stranger's faces, respectively. Thus, social comparisons of facial healthiness could provide a perceptual measure of state well-being.

Training interpretation biases among individuals with body dysmorphic disorder symptoms

The current study provided an initial test of a Cognitive Bias Modification for Interpretations (CBM-I) training paradigm among a sample with elevated BDD symptoms (N=86). As expected, BDD-relevant interpretations were reduced among participants who completed a positive (vs. comparison) training program. Results also pointed to the intriguing possibility that modifying biased appearance-relevant interpretations is causally related to changes in biased, socially relevant interpretations. Further, providing support for cognitive behavioral models, residual change in interpretations was associated with some aspects of in vivo stressor responding. However, contrary to expectations there were no significant effects of condition on emotional vulnerability to a BDD stressor, potentially because participants in both training conditions experienced reductions in biased socially-threatening interpretations following training (suggesting that the "comparison" condition was not inert). These findings have meaningful theoretical and clinical implications, and fit with transdiagnostic conceptualizations of psychopathology.

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.

Feeling bad and looking worse: negative affect is associated with reduced perceptions of face-healthiness

Some people perceive themselves to look more, or less attractive than they are in reality. We investigated the role of emotions in enhancement and derogation effects; specifically, whether the propensity to experience positive and negative emotions affects how healthy we perceive our own face to look and how we judge ourselves against others. A psychophysical method was used to measure healthiness of self-image and social comparisons of healthiness. Participants who self-reported high positive (N = 20) or negative affectivity (N = 20) judged themselves against healthy (red-tinged) and unhealthy looking (green-tinged) versions of their own and stranger’s faces. An adaptive staircase procedure was used to measure perceptual thresholds. Participants high in positive affectivity were un-biased in their face health judgement. Participants high in negative affectivity on the other hand, judged themselves as equivalent to less healthy looking versions of their own face and a stranger’s face. Affective traits modulated self-image and social comparisons of healthiness. Face health judgement was also related to physical symptom perception and self-esteem; high physical symptom reports were associated a less healthy self-image and high self-reported (but not implicit) self-esteem was associated with more favourable social comparisons of healthiness. Subject to further validation, our novel face health judgement task could have utility as a perceptual measure of well-being. We are currently investigating whether face health judgement is sensitive to laboratory manipulations of mood.

Own-body perception in body dysmorphic disorder

INTRODUCTION

This paper reviews the literature as it relates to perceptual processes in body dysmorphic disorder (BDD).

METHODS

A narrative-style review of the literature was undertaken to explore the relationship between BDD and obsessive-compulsive disorder, the empirical evidence for aberrant own-body perception in BDD, and the possible role of the parietal cortex in the disorder.

RESULTS

The extant literature appears to support the postulation that BDD is underpinned by a dysfunction in somatoperception-the process by which individuals formulate a sense of what they look like.

CONCLUSIONS

Investigation of somatoperceptive processes in BDD and related brain structures would provide important insight about the development and maintenance of this complex and often neglected psychiatric condition, and, in turn, help improve its treatment.

New developments in human neurocognition: clinical, genetic, and brain imaging correlates of impulsivity and compulsivity

Impulsivity and compulsivity represent useful conceptualizations that involve dissociable cognitive functions, which are mediated by neuroanatomically and neurochemically distinct components of cortico-subcortical circuitry. The constructs were historically viewed as diametrically opposed, with impulsivity being associated with risk-seeking and compulsivity with harm-avoidance. However, they are increasingly recognized to be linked by shared neuropsychological mechanisms involving dysfunctional inhibition of thoughts and behaviors. In this article, we selectively review new developments in the investigation of the neurocognition of impulsivity and compulsivity in humans, in order to advance our understanding of the pathophysiology of impulsive, compulsive, and addictive disorders and indicate new directions for research.

Visual processing in anorexia nervosa and body dysmorphic disorder: similarities, differences, and future research directions

Anorexia nervosa (AN) and body dysmorphic disorder (BDD) are psychiatric disorders that involve distortion of the experience of one's physical appearance. In AN, individuals believe that they are overweight, perceive their body as "fat," and are preoccupied with maintaining a low body weight. In BDD, individuals are preoccupied with misperceived defects in physical appearance, most often of the face. Distorted visual perception may contribute to these cardinal symptoms, and may be a common underlying phenotype. This review surveys the current literature on visual processing in AN and BDD, addressing lower- to higher-order stages of visual information processing and perception. We focus on peer-reviewed studies of AN and BDD that address ophthalmologic abnormalities, basic neural processing of visual input, integration of visual input with other systems, neuropsychological tests of visual processing, and representations of whole percepts (such as images of faces, bodies, and other objects). The literature suggests a pattern in both groups of over-attention to detail, reduced processing of global features, and a tendency to focus on symptom-specific details in their own images (body parts in AN, facial features in BDD), with cognitive strategy at least partially mediating the abnormalities. Visuospatial abnormalities were also evident when viewing images of others and for non-appearance related stimuli. Unfortunately no study has directly compared AN and BDD, and most studies were not designed to disentangle disease-related emotional responses from lower-order visual processing. We make recommendations for future studies to improve the understanding of visual processing abnormalities in AN and BDD.

The influence of social comparison on visual representation of one's face

Can the effects of social comparison extend beyond explicit evaluation to visual self-representation—a perceptual stimulus that is objectively verifiable, unambiguous, and frequently updated? We morphed images of participants' faces with attractive and unattractive references. With access to a mirror, participants selected the morphed image they perceived as depicting their face. Participants who engaged in upward comparison with relevant attractive targets selected a less attractive morph compared to participants exposed to control images (Study 1). After downward comparison with relevant unattractive targets compared to control images, participants selected a more attractive morph (Study 2). Biased representations were not the products of cognitive accessibility of beauty constructs; comparisons did not influence representations of strangers' faces (Study 3). We discuss implications for vision, social comparison, and body image.

Evaluating implicit attractiveness beliefs in body dysmorphic disorder using the Go/No-go Association Task

Cognitive-behavioral models of body dysmorphic disorder (BDD) suggest the disorder is characterized by exaggerated beliefs about the significance of appearance. However, previous studies assessing automatic associations regarding the importance of attractiveness failed to find any differences between individuals with BDD and healthy control participants using the Implicit Association Test (IAT; Greenwald, McGhee, & Schwartz, 1998). An open question is whether the BDD and control groups indeed implicitly evaluate attractiveness comparably, or whether methodological factors (e.g., the IAT design requirement of a relative comparison category for attractiveness) made it difficult to observe group differences. To address this question, we evaluated explicit and implicit attractiveness beliefs among individuals with BDD (n = 36), individuals with a dermatological condition (n = 36), and psychiatrically healthy control participants (n = 36) using the single target category Go/No-go Association Task (GNAT; Nosek, & Banaji, 2001). Indeed, BDD participants had significantly stronger implicit associations between attractive and important, relative to the other groups, whereas there was no difference between the dermatology and control groups. Further, the GNAT was effective at classifying individuals with BDD above and beyond the prediction offered by an explicit measure of attractiveness beliefs. The GNAT may be a useful tool for assessing implicit associations in clinical populations because it does not require an explicit comparison target category, which is a restriction of many implicit measures.

Automatic and strategic measures as predictors of mirror gazing among individuals with body dysmorphic disorder symptoms

The current study tests cognitive-behavioral models of body dysmorphic disorder (BDD) by examining the relationship between cognitive biases and correlates of mirror gazing. To provide a more comprehensive picture, we investigated both relatively strategic (i.e., available for conscious introspection) and automatic (i.e., outside conscious control) measures of cognitive biases in a sample with either high (n = 32) or low (n = 31) BDD symptoms. Specifically, we examined the extent that (1) explicit interpretations tied to appearance, as well as (2) automatic associations and (3) strategic evaluations of the importance of attractiveness predict anxiety and avoidance associated with mirror gazing. Results indicated that interpretations tied to appearance uniquely predicted self-reported desire to avoid, whereas strategic evaluations of appearance uniquely predicted peak anxiety associated with mirror gazing, and automatic appearance associations uniquely predicted behavioral avoidance. These results offer considerable support for cognitive models of BDD, and suggest a dissociation between automatic and strategic measures.