The presence, predictive utility, and clinical significance of body dysmorphic symptoms in women with eating disorders

Development of a body dysmorphic disorder screener for DSM-5 (BDDS-5)

Early identification of individuals with Body dysmorphic disorder (BDD) is essential to direct them to appropriate care and to reduce the chance of developing or maintaining comorbid psychiatric disorders (like an eating disorder (ED)). The present study aimed to develop a simple screener, the Body Dysmorphic Disorder Screener for DSM-5 (BDDS-5), to overcome existing screeners' limitations and test its psychometric properties. The BDDS-5 consists of 12 statements with dichotomous answer options. Specific attention is paid to the readability of the screener for those with lower reading skills. Additional eating disorder screening questions (S section) were added to investigate whether these questions are necessary for detecting potential BDD cases. Finally, the factor structure, internal consistency, and validity of the BDDS-5 were examined within populations with a high risk of screening positive for BDD or ED. Principal axis factor analysis showed that two factors accounted for 63.5% of the variance. The factor analysis was based on polychoric correlation. Based on the BDDS-5, 33 persons (14% of N = 235) were screened as likely BDD cases. Nineteen persons were excluded as potential BDD cases based on the eating disorder related question (question D). Based on the S-section, this turned out to be largely correct for the majority, however, in 8% (n = 4) of the cases BDD was probably missed. The convergent validity appeared to be high (r > 0.80) with three other BDD measures. The BDDS-5 is a valid and widely applicable screener for BDD that may help in the early detection of BDD. The BDDS-5 uses simple wording and is thus suitable for people 8 years and older.

Topography and relationship-specific social touching in individuals displaying body image disturbances

Interpersonal touch is intimately related to the emotional bond between the touch giver and the touch receiver. Which bodily regions we touch in those individuals in our social network is relationship specific. Perception of interpersonal touch is altered in psychiatric disorders characterised by body image disturbances (BIDs). Here, we examined whether the 'imagined' experience of social touch in individuals with BIDs is body topography- and relationship-specific. By using an interactive media mobile App, the Virtual Touch Toolkit, high versus low levels of BIDs participants completed heatmaps of full-body virtual avatars, to indicate the body regions they find soothing/unpleasant to be touched by a loved one versus an acquaintance. Self-reports of interoceptive awareness and dysmorphic concerns were also measured. Overall, imagined touch was rated as the most soothing when received from a loved one, and also when this was delivered to 'social' body regions. The importance of the social relationship for the imagined tactile interactions was particularly evident for the high levels of BIDs group, with greater problems with interoceptive awareness predicting higher soothing touch ratings when this was received by a loved one. Despite the evidence that imagined bodily contacts between meaningful people is the most pleasant for socially acceptable bodily regions, our findings may suggest a greater sensitivity to relation-specific bodily patterns of social touch particularly in the high level of BIDs group. Heightened interoceptive awareness may also play a key role in this experience of bodily affective contacts. Future research for body-oriented therapy for BIDs is encouraged to systematically probe the efficacy of imagined social touch interaction protocols which use more plausible, ecological, scenarios where touch is delivered by loved ones and to socially acceptable bodily regions.

"Can you see me?" Videoconferencing and eating disorder risk during COVID-19: Anxiety, impairment, and mediators

OBJECTIVE

The use of videoconferencing has increased during the pandemic, creating prolonged exposure to self-image. This research aimed to investigate whether eating disorder (ED) risk was associated with videoconferencing performance for work or study and to explore whether the use of safety behaviors and self-focused attention mediated the relationship between ED risk and perceived control over performance anxiety, impaired engagement, or avoidance of videoconferencing for work or study.

METHOD

In 2020, an online survey was distributed within Australia to those aged over 18 years via academic and social networks, measuring: use of videoconferencing for work/study, demographics, ED risk, safety behaviors for appearance concerns, self-focused attention, perceived control over performance anxiety, perceived engagement impairment, and avoidance of videoconferencing. A total of 640 participants (77.3% female, M_age  = 26.2 years) returned complete data and were included in analyses.

RESULTS

245 participants (38.7%) were considered at-risk for EDs (SCOFF > 2). Those at-risk reported significantly more safety behaviors, self-focused attention, impaired engagement, and avoidance, plus lower perceived control over performance anxiety than those not at-risk. Multiple mediation models found the effects of ED risk on control over performance anxiety, impaired engagement, and avoidance were partially mediated by safety behaviors and self-focused attention.

DISCUSSION

Our cross-sectional findings suggest videoconferencing for work/study-related purposes is associated with performance anxiety, impaired engagement, and avoidance among individuals at-risk for EDs. Poorer videoconferencing outcomes appear more strongly related to social anxiety variables than ED status. Clinicians and educators may need to provide extra support for those using videoconferencing.

PUBLIC SIGNIFICANCE

Because videoconferencing often involves seeing your own image (via self-view) we wondered whether the appearance concerns experienced by those with eating disorders (EDs) might interfere with the ability to focus on or to contribute to work/study videoconferencing meetings. We found that although those with EDs experience more impairments in their videoconferencing engagement/contribution, these were linked just as strongly to social anxiety as they were to appearance concerns.

Associations Between Defence-Style, Eating Disorder Symptoms, and Quality of Life in Community Sample of Women: A Longitudinal Exploratory Study

Background and Aim: Eating Disorders (EDs) impact an estimated 15% of the global population and are linked to maladaptive defence-styles (coping strategies) and poorer mental health outcomes. Defence-styles have been grouped into immature, neurotic, and mature behaviours. Studies have yet to examine all three defence-styles in ED symptomatic individuals over an extended period of time. The current study aimed to investigate using converse analysis the relationships between defence-style and ED outcomes over a 5-years period. Methods: Participants (n = 216, mean age 33 years) were recruited through the Women's Eating and Health Literacy study, with the current study examining a 5-years period of two waves (year-4 and year-9). The current study tested associations over time between eating pathology (EDE-Q), psychological distress (K10), mental and physical health related quality of life (M/PHRQoL, SF-12), and defence-style (DSQ-40). Results: Mature, immature and neurotic defence-styles did not significantly change over 5 years. Over the same period, only PHRQoL significantly predicted mature defence-styles having positive effect. Both MHRQoL and PHRQoL significantly predicted immature defence-styles having positive and negative effects, respectively. Psychological distress, PHRQoL and weight concern significantly predicted neurotic defence-styles having positive effects except for psychological distress. PHRQoL, MHRQoL, restraint and eating concern significantly predicted overall eating pathology having positive effects except for PHRQoL and MHRQoL. Conversely, among the defence-style variables, over 5 years, both immature and neurotic defence-styles significantly predicted psychological distress having positive effects, immature and mature defence-styles significantly predicted MHRQoL having negative and positive effects, respectively, while only immature defence-styles significantly predicted overall eating pathology having positive effect. Conclusions: The results of the current study suggest that immaturity and neuroticism but not maturity were the defence-style variables predicting psychological distress over a 5-years period while conversely psychological distress predicted only neurotic defence styles. The findings of the current study may suggest that without intervention, mature, immature and neurotic defence-styles may largely remain immutable to significant shifts over time. Limitations in the current study included limited demographic representation. The current study is anticipated to generate considerations into treatments that could strengthen defence-styles in individuals with increased eating pathology.

Effects associated with the use of healthcare for eating disorders by women in the community: a longitudinal cohort study

OBJECTIVES

This study examined formal and informal healthcare use (HCU) in community women with disordered eating, and associations of HCU with mental health-related quality of life (MHRQoL), psychological distress, mental health literacy (MHL) and eating disorder (ED) symptoms over time.

HYPOTHESIS

We hypothesised that HCU would lead to improvement in ED symptom severity, MHRQoL, MHL and psychological distress.

DESIGN, SETTING, PARTICIPANTS

Data were from years 2, 4 and 9 of a longitudinal cohort of 443 community women (mean age 30.6, SE 0.4 years) with a range of ED symptoms, randomly recruited from the Australian Capital Territory electoral role or via convenience sampling from tertiary education centres. Data were collected using posted/emailed self-report questionnaires; inclusion criteria were completion of the HCU questionnaire at time point of 2 years (baseline for this study). HCU was measured using a multiple-choice question on help seeking for an eating problem. To test the effect of HCU over time on MHRQoL (Short Form-12 score), psychological distress (Kessler Psychological Distress Scale score), ED symptom severity (Eating Disorder Examination Questionnaire score) and ED-MHL, linear or logistic mixed-effects regression analyses were used.

RESULTS

20% of participants sought ED-specific help at baseline; more than half of participants sought help that was not evidence based. HCU at baseline was significantly associated with improved MHRQoL and ED symptom severity and decreased psychological distress over time (Cohen's d all >0.3, ie, small). HCU was not significantly associated with MHL over time. The predictive ability of the fitted models ranged from 32.18% to 42.42% for psychological distress and MHL treatment, respectively.

CONCLUSIONS

Formal and informal HCU were associated with small improvements in ED symptoms, MHRQoL and psychological distress but not with improved MHL. Informal services in ED management should be investigated further along with efforts to improve ED-MHL.

Factor structure and psychometric properties of the Spanish version of the Body Image Avoidance Questionnaire (BIAQ)

PURPOSE

The main objective of this study was to analyse the factor structure and psychometric properties of a Spanish validation of the Body Image Avoidance Questionnaire (BIAQ) in a community sample of adolescents.

METHODS

A total of 4283 people (55.9% girls, aged 12-18) participated.

RESULTS

Confirmatory factor analysis corroborated four first-order factors related to a second-order factor including the total BIAQ score, with excellent fit and invariance across sex. The total internal consistency of the questionnaire was adequate, although two factors showed low reliability. Strong relationships were found with scales evaluating preoccupation with weight and dysmorphic concerns, and moderate correlations with dissatisfaction and investment in appearance. It was found that 24.06% of adolescents with body image disturbance could be at risk of developing a body image disorder.

CONCLUSIONS

The results of this study support the use of the Spanish translation of the BIAQ for assessing behavioural characteristic of body image disturbance.

LEVEL OF EVIDENCE

V, cross-sectional descriptive study.

Protect me from my selfie: Examining the association between photo-based social media behaviors and self-reported eating disorders in adolescence

OBJECTIVE

This study examined whether social media behaviors were associated with higher odds of meeting criteria for an eating disorder and whether gender moderated these relationships.

METHOD

Australian adolescents (N = 4,209; 53.15% girls) completed the self-report photo investment and manipulation scales. Additional self-report items assessed avoidance of posting selfies and investment in others' selfies. Eating disorders were identified by the Eating Disorder Examination Questionnaire and other self-report measures aligned with diagnostic and statistical manual for mental disorders-5 criteria.

RESULTS

A multinomial logistic regression examining the effect of avoidance of posting selfies, photo investment, photo manipulation, and investment in others' selfies on the likelihood of meeting criteria for an eating disorder, compared to no disorder, was significant (χ² [42] = 1,128.93, p < .001). Greater avoidance was associated with higher odds of meeting criteria for all disorders except clinical/subclinical binge-eating disorder and purging disorder. Increased photo investment was related to greater odds of meeting criteria for all disorders. A similar relationship emerged for photo manipulation, with the exception of clinical/subclinical binge-eating disorder, and unspecified feeding and eating disorder. Investment in others' selfies was associated with higher odds of meeting criteria for all disorders except clinical/subclinical anorexia nervosa and purging disorder. There was a significant interaction between gender and avoidance (χ² [1] = 5.23, p = .025, OR = 1.74), whereby boys were more likely to meet criteria for clinical/subclinical anorexia nervosa in the context of greater avoidance of posting selfies.

DISCUSSION

Appearance-related social media behaviors may be indicative of eating disorder risk. Implications for clinicians and advancements for social media screening tools are discussed.

Body parts of clinical concern in anorexia nervosa versus body dysmorphic disorder: a cross-diagnostic comparison

OBJECTIVES

Anorexia nervosa and body dysmorphic disorder share a hallmark clinical feature of severe body image disturbance. This study aimed to document major demographic and clinical characteristics in anorexia nervosa versus body dysmorphic disorder, and it was the first to compare specific body parts related to body image dissatisfaction across these disorders directly.

METHODS

Anorexia nervosa (n=26) and body dysmorphic disorder (n=24) patients were administered a range of clinical measures, including key questions about the specificities of their body image concerns.

RESULTS

Results revealed increased psychiatric and personality co-morbidities in anorexia nervosa relative to body dysmorphic disorder. The anorexia nervosa group was mostly preoccupied with three body zones typically linked to weight concerns, whereas the body dysmorphic disorder group fixated on facial features, hair and skin.

CONCLUSIONS

These findings may help inform differential diagnosis in complex cases and aid in the formulation of targeted interventions.

Disturbed Eating and Body Dysmorphic Symptoms in a Young Adult Sample Are Separable Constructs That Each Show a Mixture of Distributions

Eating disorder and body dysmorphic disorder symptoms overlap and frequently co-occur clinically, yet whether they represent one or more underlying constructs in the general population is unknown. We examined relationships between these symptoms on underlying factor structures and dimensional distributions in a young adult sample of 328 students using the Eating Disorder Examination-Questionnaire (EDE-Q 6.0) and the Dysmorphic Concern Questionnaire (DCQ). We performed factor and hierarchical cluster analyses on pooled items and Gaussian mixture modeling on score distributions. EDE-Q 6.0 and DCQ total scores were correlated (r = 0.53, p < .001). Pooled items demonstrated a three-factor solution; DCQ items separating from two EDE-Q 6.0 factors. Hierarchical clustering yielded a two-cluster solution that separated the two scales. Mixture modeling demonstrated that more than one underlying distribution best fit the data for each scale. These results suggest that the EDE-Q 6.0 and DCQ measure different sets of psychopathological features, despite their tendency to track together. Moreover, eating disorder and body dysmorphic phenotypes each show nonuniform variation from normal to abnormal. This argues against using linear dimensional applications of these scales to assess individuals ranging from mild to severe in symptom severity. Separate scales may be necessary to characterize lower and higher ranges of clinical severity.

Evidence for altered configural body processing in women at risk of disorders characterized by body image disturbance

Two studies were conducted to assess appearance-related visual processing mechanisms in populations at risk of disorders characterized by body image disturbance. Using inverted stimuli, Experiment 1 assessed visual processing mechanisms associated with body, face, and house viewing in adolescents. Experiment 2 applied the same protocol to assess appearance-related configural processing in high- and low-risk adolescent women, and women recovering from disorders characterized by body image disturbance. Experiment 1 found evidence for typical configural face and body processing, although adolescent women reported higher levels of body image concern (BIC) and self-objectified to a greater extent than adolescent men. In Experiment 2, typical body inversion effects were seen in the low-risk group, whilst there was some evidence to suggest a disruption to the configural processing of body stimuli in high-risk adolescents and in women recovering from body image disorders. Women in recovery were also quicker to respond to all stimuli, whilst high-risk adolescents took longer to respond to bodies than to other stimuli. Configural face processing was intact in all groups, and effects did not directly relate to BIC or self-objectification. These findings have implications for future research looking to inform early interventions and treatment, suggesting that there could be a tendency to visually process individual body parts at the expense of the whole-body form in women at risk of developing body image disorders, as well as those in recovery.

Self-silencing and women's health: A review

The connection between gender and health has intrigued health professionals in the last few decades. Silencing-the-self theory has brought a considerable clarity in this matter. After around three decades of the theory, the literature related to the theory has immensely flourished and has covered different branches of psychology. The aim of the present work is to provide a comprehensive picture of the qualitative and quantitative research findings that have connected self-silencing to health and well-being of women. This article presents a critical review of relevant articles. These articles have used the self-silencing theory as an explanation of women's higher vulnerability to certain diseases as well as their experience with them. Self-silencing has been found to explain the gender gap in psychiatric disorders like depression, eating disorders and so on. It also influences the resilience and therapeutic effects among female patients with chronic conditions such as cancer, AIDS and so on. Moreover, self-silencing has also been found to be associated with women's health issues such as pre-menstrual dysphoric disorder. The present study discusses the existing literature in a narrative manner along with suggesting some relevant research gaps that can be worth exploring in the future.

Non-weight-related body image concerns and Body Dysmorphic Disorder prevalence in patients with Anorexia Nervosa

Patients with Anorexia Nervosa (AN) and patients with Body Dysmorphic Disorder (BDD) are both characterized by body image disturbance and dissatisfaction; furthermore, these disorders share clinical features and frequently co-occur. However, few studies have explored the relation between AN and BDD. Therefore, the first aim of the study was assessing the prevalence of BDD and presence of non-weight-related body image concerns in patients with AN. Second, we were interested in comparing patients with AN and non-weight-related body image concerns, patients with weight-related body image concerns only, and a healthy control group with respect to several psychological and psychopathological features. Sixty-one female patients with AN were divided in two subgroups: 39 with non-weight-related body image concerns and 22 with weight-related body image concerns only. Sixteen (26.23%) patients with AN had probable comorbid BDD. Moreover, patients with AN and non-weight-related body image concerns reported, overall, greater psychopathology than patients with AN and weight-related body image concerns only, with the exception of AN core features and general distress. In conclusion, patients with AN and non-weight-related body image concerns showed a more severe body image disturbance unrelated to a more severe eating disorder pathology.

Two sides of the same coin? A new instrument to assess body checking and avoidance behaviors in eating disorders

Body checking (BC) and avoidance behaviors (BA) are the dominant behavioral features of body image disturbances (BID) that characterize most individuals with eating disorders (EDs). Whereas BC can be reliably assessed, a valid assessment tool for BA is lacking, preventing an adequate assessment of BID differences across different EDs (anorexia nervosa, AN; bulimia nervosa, BN; binge eating disorder, BED). A total of 310 women with EDs and 112 nonclinical controls completed measures of BC-, BA- and ED-related symptoms. BA did not differentiate between EDs, whereas BC did: it was highest in AN and BN, and lowest in BED. Multivariate analyses also discriminated AN from BN based on BC. Given that results are of preliminary nature, evidence is promising that EDs can be discriminated from healthy controls and that differential BID profiles for the behavioral component among ED subgroups exist. However, replication of the factor structure remains open within ED subsamples.

Disentangling body image: The relative associations of overvaluation, dissatisfaction, and preoccupation with psychological distress and eating disorder behaviors in male and female adolescents

OBJECTIVE

The distinctiveness and relative clinical significance of overvaluation, dissatisfaction, and preoccupation with body weight/shape remains inconclusive. This study sought to add to the evidence by testing associations between these three body image constructs and indicators of clinical significance.

METHOD

Male and female secondary students (N = 1,666) aged 12-18 years completed a survey that included measures of dissatisfaction with, overvaluation of, and preoccupation with weight/shape, psychological distress, eating disorder behaviors, and basic demographic information. Conditional process analysis was employed to test the independent and mediating effects of overvaluation, dissatisfaction, and preoccupation on distress, dietary restraint, and objective binge eating.

RESULTS

Overvaluation, dissatisfaction, and preoccupation were highly correlated (r = 0.47-0.84). In girls, preoccupation demonstrated the strongest independent and mediating effects on distress, dietary restraint, and binge eating; whereas neither the direct or indirect effects of dissatisfaction on distress and overvaluation on binge eating were significant. Among boys however, the direct and indirect effects of overvaluation, dissatisfaction, and preoccupation on distress and eating disorder behaviors were relatively equal.

DISCUSSION

Preoccupation with weight/shape may be particularly clinically significant in girls, whereas all constructs of body image disturbance may be equally clinically significant in boys. The findings are consistent with the view that these constructs, while closely related, are distinct. © 2016 Wiley Periodicals, Inc.(Int J Eat Disord 2017; 50:118-126).

The bidirectional relationship between quality of life and eating disorder symptoms: a 9-year community-based study of Australian women

OBJECTIVE

Studies that have investigated quality of life (QoL) in eating disorders (EDs) have been focussed on the impact of the ED on QoL and little is known regarding the possible reciprocal impact of QoL on EDs. The aim of this study was to provide a first-time investigation of possible bidirectional relationships between EDs and both health-related QoL (HRQoL) and psychological distress (PD).

METHOD

Structural equation modeling was applied to longitudinal data collected from a community sample of Australian women (N = 828) surveyed at baseline, five annual follow-ups, and again after nine years. Participants reported height and weight (from which body mass index, BMI, was calculated) and completed measures of ED symptoms (Eating Disorder Examination Questionnaire), HRQoL (12-item Medical Outcomes Study Short Form), and PD (Kessler Psychological Distress Scale).

RESULTS

Overall, evidence was found for a bidirectional relationship, whereby ED symptoms predicted reduced HRQoL and greater PD over time, while lower levels of HRQoL and greater PD in turn predicted increased levels of ED symptoms. These relationships were stable, observable within 12 months, and remained observable over a time period of at least four years. However, also observed were some inconsistent findings where ED symptoms predicted a short term (one year) improvement in mental HRQoL. This short term boost was not sustained at longer follow-ups.

CONCLUSIONS

Not only do ED symptoms impact on HRQoL and PD, but perceived poor HRQoL and PD also contribute to ED symptom development or exacerbation. This supports a movement away from symptom-centric approaches whereby HRQoL is conceptualized as a passive outcome expected to be rectified by addressing ED symptoms. Improvement in QoL and PD might rather be viewed as targets to be pursued in their own right under broader approaches in the treatment of EDs.

Epidemiology of eating disorders, eating disordered behaviour, and body image disturbance in males: a narrative review

Challenges to epidemiological studies of eating and related body image disturbance disorders in males include, in addition to low base rates and the predominance of residual diagnostic categories, the female-centric nature of current classification schemes and the consequent lack of appropriate assessment instruments. In this narrative review, we summarise epidemiological data regarding the prevalence and correlates of eating disorders, related body image disturbance disorders, and eating disorder features in males. Attention is focused on disorders most likely to be observed among males, such as muscle dysmorphia and muscularity-oriented excessive exercise. It is argued that, given the multiple challenges involved in research of this kind, a focus on features is more likely to advance the field than a focus on diagnoses. In terms of correlates, we focus on impairment and help-seeking, since these issues are most relevant in informing public health burden, service provision, and related issues. We end with some thoughts about current gaps in the knowledge base and directions for future research that we consider to be most promising.