Models Of Body Dysmorphic Disorder Research Articles

Facial symmetry perception and attractiveness ratings in body dysmorphic disorder

Cognitive-behavioral models of body dysmorphic disorder (BDD) conceptualize biases in visual information processing as maintaining factors of the disorder. Empirical findings point to selective attentional mechanisms and a detail-oriented information processing style in facial perception, which are related to perceived facial aesthetics. However, so far, it remains unclear whether higher discrimination abilities of facial symmetry and related attractiveness ratings contribute to the mind as a filter in BDD. BDD (n = 25) and mentally healthy subjects (n = 25) rated symmetry and attractiveness of fifty animated, three-dimensional facial photographs characterized by diverging geometrical symmetry. Main findings emerging from mixed effects models indicated that perceived symmetry, but not objective symmetry, predicted perceived attractiveness. Group status did not predict symmetry or attractiveness ratings. Exploratory analyses indicated potentially clinically relevant mechanisms of symmetry ratings in BDD and revealed faster attractiveness ratings in unattractive vs. attractive faces across groups. Our findings refute the hypothesis of higher discrimination abilities of facial symmetry as a maintaining factor in BDD. Implications for attention and perception retraining in the context of cognitive-behavioral therapy for BDD are discussed.

Extending the cognitive-behavioral model of Body Dysmorphic Disorder: The role of attachment anxiety and self-ambivalence

This study aimed to extend the cognitive-behavioral model of Body Dysmorphic Disorder (BDD) by exploring the role of insecure attachment and self-ambivalence on the relationship between two specific cognitive factors, namely appearance orientation (seeing the self as an aesthetic object) and appearance evaluation (negative appraisal of internal body image), on levels of BDD severity. A convenience sample of 304 Australian residents (72.4% females) completed online self-report measures; 53% reported clinical or subclinical levels of BDD. Attachment anxiety and self-ambivalence were both associated with BDD severity, as were both cognitive factors. The direct effect of attachment anxiety was no longer significant after controlling for self-ambivalence, appearance orientation and evaluation. However, significant specific indirect effects were found suggesting that individuals who report greater levels of insecure attachment and self-ambivalence exhibit greater appearance orientation and negative appearance evaluation which, in turn, results in higher levels of BDD. The indirect effect through self-ambivalence was strongest suggesting a central role of self in the relationship between attachment anxiety and BDD severity. The current research demonstrates the importance of attachment anxiety and self-ambivalence in the context of BDD and implicates their potential role in treatment; however, further clinical studies are needed.

Young people’s experiences of body dysmorphic disorder in education settings: a grounded theory

ABSTRACT Body dysmorphic disorder (BDD) is characterised by a distressing preoccupation with perceived defects or flaws in one’s appearance. BDD most typically emerges in adolescence and is estimated to affect 2.2% of the UK adolescent population. There is a dearth of research into children’s and young people’s lived experiences of BDD, particularly in relation to educational contexts. Using Constructivist Grounded Theory methodology, interview data from 10 young people between the ages of 16 and 25 were analysed for this study. Findings informed the development of a psychological model of BDD in young people: The Shame-Identity Model of BDD in Young People. This paper focuses on the educational aspects within this model. Implications for educational professionals are discussed.

Minority stress and body dysmorphic disorder symptoms among sexual minority adolescents and adult men

Body dysmorphic disorder (BDD) has a prevalence rate of 2.4 % among U.S. adults; however, little is known about BDD among sexual minority men. Minority stressors (fear of rejection, sexual orientation concealment, internalized homophobia, discrimination/prejudice) may be risk factors for BDD in this population. Thus, the purpose of the current study was to estimate the occurrence of BDD in a sample of sexual minority men and investigate associations between minority stressors and BDD. Participants were recruited via social media, and survey data were collected from 268 sexual minority adolescent boys and adult men (M = 24.59 years, SD = 5.37 years). Regression models included either positive BDD screen or levels of BDD symptoms as dependent variables and the four aforementioned minority stressors as explanatory variables. The occurrence rate of positive BDD screens was 49.3 %. Gay-related rejection sensitivity and sexual orientation concealment were uniquely associated with greater BDD symptoms, and sexual orientation concealment was uniquely associated with greater odds of positive BDD screens. Given the high occurrence of positive BDD screens in the current sample, compared to the national prevalence, sexual minority stressors may be worthy to explore in etiological models of BDD in this population.

Experimental induction of self-focused attention via mirror gazing: Effects on body image, appraisals, body-focused shame, and self-esteem

Cognitive and behavioural models of body dysmorphic disorder posit that selective self-focused attention via mirror gazing plays a key role in the aetiology and maintenance of the disorder. However, there is little empirical support for these theoretical claims. This study aimed to induce self-focused attention via mirror gazing to examine the proposed theoretical effects on body image, distress, body-focused shame, and self-esteem. Fifty-one non-clinical participants (78.43% female) were randomly allocated to one of the two conditions: low self-focused attention (i.e., looking into a mirror placed 100 cm/ 39 in away) vs. high self-focused attention (i.e., focusing on a disliked part in a mirror placed 10 cm/ 4 in away). Following 5 min of mirror gazing, the high self-focused attention condition experienced decreased satisfaction with appearance, perceived attractiveness, and self-esteem, and increased distress about appearance, distress about disliked parts, urges to change appearance, and body-focused shame. Approaching the mirror from a distance appeared to have no effect. Findings are consistent with theories suggesting that self-focused attention and mirror behaviours might contribute to the development of body dysmorphic disorder and maintain its psychological effects.

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

Background and objectivesInterpretation 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. MethodsWe 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. ResultsThe 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. LimitationsLimitations pertaining to sample characteristics, training and assessment overlap, and stressor task design are discussed. ConclusionsFindings 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.

Maternal Rejection and Idealized Value of Appearance: Exploring the Origins of Body Dysmorphic Concerns Among Young Adults.

Body dysmorphic disorder is a clinical disorder characterized by a preoccupation with an imagined or exaggerated defect in one's appearance (American Psychological Association, 2013), causing impaired functioning. Cognitive-behavioral models of body dysmorphic disorder have been proposed, whereby social anxiety and parental rejection may be predisposing factors, whereas maladaptive cognitive biases, such as appraisals of rejection, may serve as maintenance factors. The primary aim of this study was to test the role that perceived parental rejection in childhood may play in understanding the development of body dysmorphic symptoms. Furthermore, this study examined whether idealized values of appearance act as a mediator between perceived maternal rejection and body dysmorphic symptoms. The sample comprised 239 Australian undergraduate psychology students. Social anxiety, appearance-based rejection sensitivity, maternal rejection, and idealized values of appearance uniquely predicted body dysmorphic symptoms. Furthermore, the relationship between maternal rejection and body dysmorphic symptoms was partially mediated by idealized values of appearance. Findings support cognitive-behavioral models of body dysmorphic disorder.

Inferring other people's states of mind: Comparison across social anxiety, body dysmorphic, and obsessive–compulsive disorders

BackgroundSocial anxiety disorder (SAD) and body dysmorphic disorder (BDD) are characterized by fears of negative evaluation by others (related to one's own incompetence or flawed appearance, respectively). Previous research has shown that individuals with SAD and BDD exhibit difficulty identifying facial expressions and interpretive biases for threat in social situations. The current study aimed at further investigating social cognition in SAD, BDD, and mentally healthy controls (35 individuals per group, respectively). Further, 35 individuals with obsessive–compulsive disorder (OCD) as a clinical control group not characterized by evaluation fears were included. MethodsThe Movie for the Assessment of Social Cognition (MASC) was applied. It consists of 45 video sequences depicting interactions among four people at a dinner party. Participants are instructed to evaluate each scenario with respect to the characters' emotions, thoughts, and intentions from a bystander perspective (i.e. other-referent context). ResultsOnly the socially anxious groups (SAD and BDD) were overall less accurate than the other groups in correctly interpreting the social situations, whereas no difference was obtained between the OCD and the control group. Further analyses indicated that the SAD and BDD groups were less accurate in identifying other people's thoughts and intentions, whereas, again, no difference was observed between the OCD and control groups. In addition, the SAD group was less accurate in inferring thoughts and intentions than the OCD group. Interestingly, the groups did not differ with respect to identifying other people's emotions. ConclusionsThese results mostly confirm existing cognitive-behavioral models of SAD and BDD emphasizing that biased interpretation of what others think or intend is one of the key factors maintaining social anxiety and appearance-related concerns. Our study shows that this bias generalizes to social situations in which individuals take a third-person observer perspective.

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.

Therapist-guided, Internet-based cognitive-behavioural therapy for body dysmorphic disorder (BDD-NET): a feasibility study.

ObjectivesCognitive–behavioural therapy (CBT) is an effective treatment for body dysmorphic disorder (BDD). However, most sufferers do not have access to this treatment. One way to increase access to CBT is to administer treatment remotely via the Internet. This study piloted a novel therapist-supported, Internet-based CBT program for BDD (BDD-NET).DesignUncontrolled clinical trial.ParticipantsPatients (N=23) were recruited through self-referral and assessed face to face at a clinic specialising in obsessive–compulsive and related disorders. Suitable patients were offered secure access to BDD-NET.InterventionBDD-NET is a 12-week treatment program based on current psychological models of BDD that includes psychoeducation, functional analysis, cognitive restructuring, exposure and response prevention, and relapse prevention modules. A dedicated therapist provides active guidance and feedback throughout the entire process.Main outcome measureThe clinician-administered Yale-Brown Obsessive Compulsive Scale for BDD (BDD-YBOCS). Symptom severity was assessed pretreatment, post-treatment and at the 3-month follow-up.ResultsBDD-NET was deemed highly acceptable by patients and led to significant improvements on the BDD-YBOCS (p=<0.001) with a large within-group effect size (Cohen's d=2.01, 95% CI 1.05 to 2.97). At post-treatment, 82% of the patients were classified as responders (defined as≥30% improvement on the BDD-YBOCS). These gains were maintained at the 3-month follow-up. Secondary outcome measures of depression, global functioning and quality of life also showed significant improvements with moderate to large effect sizes. On average, therapists spent 10 min per patient per week providing support.ConclusionsThe results suggest that BDD-NET has the potential to greatly increase access to CBT, at least for low-risk individuals with moderately severe BDD symptoms and reasonably good insight. A randomised controlled trial of BDD-NET is warranted.Trial registration numberClinicaltrials.gov registration ID NCT01850433.

Seeing “changes" that aren’t there: Facial and object discrimination in body dysmorphic disorder

Cognitive–behavioral models of body dysmorphic disorder (BDD) suggest the disorder is characterized by several interpretive, attentional, and perceptual biases that contribute to its maintenance or even development. In addition, the role of aesthetic sensitivity has been discussed in BDD. However, previous research examining the ability to identify subtle changes in facial features and geometrical objects has produced mixed results. The purpose of the current study was to further evaluate facial and object discrimination among individuals with BDD (n=35), individuals with a dermatological condition (n=35), and mentally healthy control participants (n=35) using a facial and object discrimination paradigm assessing the sensitivity for changes in symmetry, color, and size. Overall, the groups did not differ with respect to their performance in detecting actual changes in facial or object images. However, there was a significant group difference when they were presented with a series of unchanged facial but not object images: the BDD group rated identical facial images significantly more often as being changed, relative to individuals without BDD. The current results are discussed in light of the existing literature on facial and object discrimination in BDD.

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

BackgroundBoth eating disorders (EDs) and body dysmorphic disorder (BDD) are disorders of body image. This study aimed to assess the presence, predictive utility, and impact of clinical features commonly associated with BDD in women with EDs.MethodsParticipants recruited from two non-clinical cohorts of women, symptomatic and asymptomatic of EDs, completed a survey on ED (EDE-Q) and BDD (BDDE-SR) psychopathology, psychological distress (K-10), and quality of life (SF-12).ResultsA strong correlation was observed between the total BDDE-SR and the global EDE-Q scores (r = 0.79, p < 0.001). Multivariate analyses demonstrated that participants with probable EDs (n = 61) and BDD (n = 23) scored higher on 28 of the 30 BDDE-SR items compared to healthy controls (n = 173; all p < 0.05), indicating greater severity of BDD symptoms. BDD participants also scored higher than ED participants on 15 of the 30 BDDE-SR items (all p < 0.05). The remaining 15 items that ED and BDD participants scored similarly on (all p > 0.05) measured appearance checking, reassurance-seeking, camouflaging, comparison-making, and social avoidance. In addition to these behaviors, inspection of sensitivity (Se) and specificity (Sp) revealed that BDDE-SR items measuring preoccupation and dissatisfaction with appearance were most predictive of ED cases (Se and Sp > 0.60). Higher total BDDE-SR scores were associated with greater distress on the K-10 and poorer quality of life on the SF-12 (all p < 0.01).ConclusionsClinical features central to the model of BDD are common in, predictive of, and associated with impairment in women with EDs. Practice implications are that these features be included in the assessment and treatment of EDs.

Body image concern and selective attention to disgusting and non-self appearance-related stimuli

Although selective attention to one's own appearance has been widely documented in studies of body dysmorphic disorder (BDD), little is known about attentional bias toward non-self appearance-related stimuli in BDD. Furthermore, despite reports of heightened experience of disgust in BDD, it is unknown whether these individuals differentially attend to disgusting stimuli and whether disgust is important in processing of unattractive stimuli. We used a dot probe procedure to investigate the relationship between dysmorphic concern, a defining feature of BDD, and selective attention to faces, attractive, unattractive and disgusting images in a female heterosexual student population (N=92). At the long stimulus presentation (1000ms), dysmorphic concern was positively associated with attention to faces in general and attractive appearance-related images. In contrast, at the short stimulus presentation (200ms), there was a positive association between dysmorphic concern and disgusting images. Implications for theoretical models of BDD are discussed.

The relationship between body dysmorphic concerns and the effects of image suppression: Implications for models of body dysmorphic disorder

A key clinical feature of body dysmorphic disorder (BDD) is the use of avoidance behaviours to minimise discomfort associated with perceived defects in appearance. While overt avoidance, such as avoidance of social situations, has been well-documented (e.g., Phillips, 2005), covert avoidance, such as image suppression, has not been explored. This study investigated the role of suppression of negative self-imagery in the maintenance of dysmorphic concern. Undergraduate participants completed a thought suppression paradigm with an experimentally-constructed negative self-image as the target. Dysmorphic concern was associated with how distressing and vivid an appearance-related intrusion was, although it did not affect whether participants engaged in suppression of the intrusion. Instructions to suppress the image led to reduced intrusion frequency and discomfort but it did not affect the quality (e.g., vividness) of intrusions. In addition, participants high in dysmorphic concern were more likely to internalise distorted appearance-related information and be disgusted by that information. Implications for models of body dysmorphic disorder are discussed.

Perceived Appearance-Related Teasing in Body Dysmorphic Disorder: A Population-Based Survey

Body dysmorphic disorder (BDD) is characterized by perceived defects in one's physical appearance (e.g., facial asymmetry). Cognitive-behavioral models of BDD suggest that several factors, including negative appearance-related beliefs and life experiences, such as teasing, might be related to BDD's unique symptomatology. Research on perceived teasing in BDD is still limited, and the relationships previously found have been based on small sample sizes. In the current study, we investigated perceived appearance-related teasing in the German population (total N = 2,510; BDD group: n = 45; age and gender-matched non-BDD group: n = 45). As expected, the BDD group reported significantly more teasing than did the non-BDD group (40.0% vs 15.6%). Whereas no group difference was obtained regarding the years of age at the first teasing incident, the BDD group remembered the teasing experience more vividly (p = .008) and as more traumatic (p = .002). This study provides further evidence for perceived teasing in BDD.

Mirror gazing in body dysmorphic disorder and healthy controls: Effects of duration of gazing

Cognitive-behavioural models of body dysmorphic disorder (BDD) suggest that mirrors can act as a trigger for individuals with BDD, resulting in a specific mode of cognitive processing, characterised by an increase in self-focussed attention and associated distress. The aim of the current study was to investigate these factors experimentally by exposing participants with BDD (n=25) and without BDD (n=25) to a mirror in a controlled setting. An additional aim was to ascertain the role of duration of mirror gazing in the maintenance of distress and self-consciousness by manipulating the length of gazing (short check vs. long gazing). Findings demonstrated that contrary to what was predicted, not only participants with BDD, but also those without BDD experienced an increase in distress and self-focused attention upon exposure to the mirror. In addition, people without BDD, unlike those with BDD, experienced more distress when looking in the mirror for a long period of time as opposed to a short period of time. This lends some support to the idea that, for people with BDD, gazing in a mirror, regardless of duration, might act as an immediate trigger for an abnormal mode of processing and associated distress, and that this association has developed from past excessive mirror gazing. Further theoretical implications of these findings, as well as subsidiary research questions relating to additional cognitive factors are discussed.

The relationship between body dysmorphic disorder symptoms and self‐construals

Background: Cognitive models of body dysmorphic disorder (BDD) suggest that beliefs and evaluations related to self‐concept are central to the maintenance of the disorder, but such beliefs have received little empirical attention. This study examined the relative importance of contingent self‐worth and self‐ambivalence to BDD symptoms in comparison to their importance to obsessive–compulsive disorder and social phobia symptoms.Method: The sample comprised 194 non‐clinical participants (female, N = 148; males, N = 46) with a mean age of 24.70 years (standard deviation = 9.34). Participants were asked to complete a battery of self‐report questionnaires.Results: While significant relationships were found between the self‐beliefs and symptoms of all three disorders, some specificity was found in the relationships.Conclusions: Self‐worth based upon appearance was most important in BDD, while contingent self‐worth based on the approval of others was important in social phobia. Self‐ambivalence was associated with each disorder. Implications and limitations are discussed.

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.

Facial asymmetry detection in patients with body dysmorphic disorder

Cognitive-behavioral models of body dysmorphic disorder (BDD) propose that individuals with BDD may possess a better or more developed sense of aestheticality than do individuals without BDD. Evidence for this proposition, however, is limited. One perceptual process that could contribute to heightened aestheticality is the ability to detect differences in symmetry. In this experiment we tested whether individuals with BDD (n=20), relative to individuals with obsessive compulsive disorder (OCD; n=20) and healthy controls (n=20), show an enhanced ability to detect differences in the symmetry of others’ faces, symmetry of dot arrays, and/or show a greater preference for symmetrical faces. Individuals with BDD were not significantly more accurate in detecting differences in facial symmetry or dot arrays relative to individuals with OCD and healthy controls. Individuals with OCD took longer to make facial symmetry judgments than did individuals in the other two groups. All participants, regardless of diagnostic group, preferred more symmetrical faces than nonsymmetrical ones. Taken together, our results do not support a heightened perceptual ability or evaluative preference for symmetry among individuals with BDD.

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.