Potential link between body dysmorphic disorder symptoms and alexithymia in an eating-disordered treatment-seeking sample

This study aimed to explore the manifestation of body dysmorphic disorder symptoms in a sample of people with eating disorders and to investigate possible associations between body dysmorphia and alexithymia. Forty patients currently seeking treatment for an eating disorder completed a battery of six measures assessing alexithymia, mood, eating behaviours, weight-related body image, body dysmorphia and non-weight related body image. Significant moderate positive correlations (Pearson's r) between selected variables were found, suggesting that participants with high levels of dysmorphic concern (imagined ugliness) have more difficulty with the affective elements of alexithymia, that is, identifying and describing feelings. When depression, eating attitudes, and weight-related body image concerns were controlled for, significant moderate positive correlations between this alexithymia factor and dysmorphic concerns remained present. An independent-samples t-test between eating-disordered participants with and without symptoms of body dysmorphic disorder (BDD) revealed significant group differences in difficulties identifying feelings. This pattern of results was replicated when the groups were identified on the basis of dysmorphic concerns, as opposed to BDD symptoms. This study highlights the associations between alexithymia and body dysmorphia that have not previously been demonstrated.     

Body Dysmorphic Disorder: A Review of the Current Knowledge

Body Dysmorphic Disorder (BDD) is an excessive preoccupation with an imagined, or real, slight defect in normal physical appearance. The disorder, which usually begins during adolescence, tends to be chronic, and probably is much more common than is usually thought. This review presents an overview of the available scientific literature of BDD. It provides information about historical aspects, epidemiology, clinical features, aetiology, and instruments for assessing BDD. The relationship of BDD with other psychiatric disorders such as depression, obsessive-compulsive disorders, anxiety disorders, schizophrenia, eating disorders and personality disorders is discussed. Aetiological theories, including psychological and neurobiological explanations, are reviewed. Finally, psychopharmacological and psychotherapeutic treatment approaches are presented with special regard to treatment with serotonin-reuptake inhibitors, behavioural therapy and cognitive-behavioural therapy.     

Body dysmorphic disorder. Epidemiology, clinical symptoms, classification and differential treatment indications: an overview

Body dysmorphic disorder (BDD), also known as dysmorphophobia, is a relatively common disorder that consists of preoccupation with some imagined or slight defect in physical appearance. The preoccupation causes emotional distress and social impairment. Overvalued ideation and referential thinking are prevalent. BDD has a rich tradition in European psychiatry, but it first entered the official psychiatric nomenclature as a separate disorder in DSM-III-R in 1987. In the last 10 years it has received increasing empirical attention. BDD has been hypothesized to be related to obsessive-compulsive disorder (OCD) or may be conceptualized as hypochondriacal disorder. According to its body image disturbance it has been related to cenesthesia, eating disorders, and transsexualism. This paper presents the current level of awareness about BDD based on an analysis of the relevant literature. Empirical data are summarized and clinical signs are described. Varying therapies are critically reviewed.     

Suicidal ideation and suicide attempts in body dysmorphic disorder

OBJECTIVE: Because suicidality in body dys-morphic disorder (BDD) has received little investigation, this study examined rates, correlates, predictors, and other aspects of suicidal ideation and suicide attempts in this disorder. METHOD: From January 2001 to June 2003, 200 subjects with DSM-IV BDD recruited from diverse sources were assessed with standard measures. RESULTS: Subjects had high rates of lifetime suicidal ideation (78.0%) and suicide attempts (27.5%). Body dysmorphic disorder was the primary reason for suicidal ideation in 70.5% of those with a history of ideation and nearly half of subjects with a past attempt. Suicidal subjects often did not reveal their BDD symptoms to their clinician. In univariate analyses, both suicidal ideation and suicide attempts were associated with lifetime functional impairment due to BDD (p < .001), current functional impairment (p < .001 to < .05), lifetime bipolar disorder (p < .05), any personality disorder (p < .05 to .001), and comorbid borderline personality disorder (p < .01 to < .001). A history of suicidal ideation (but not suicide attempts) was additionally associated with comorbid lifetime major depression (p = .001). A history of suicide attempts (but not suicidal ideation) was additionally associated with delusional appearance beliefs (p = .01) and lifetime posttraumatic stress disorder (PTSD), an eating disorder, or a substance use disorder (p < .001 to < .05). In logistic regression analyses, suicidal ideation was significantly predicted by comorbid major depression (p = .010) and greater lifetime impairment due to BDD (p = .003); suicide attempts were significantly predicted by PTSD (p = .011), a substance use disorder (p = .011), and greater lifetime impairment due to BDD (p = .005). CONCLUSION: Individuals with BDD have high rates of suicidal ideation and suicide attempts. Lifetime impairment due to BDD and certain comorbid disorders are associated with suicidality.     

Insight impairment in body image disorders: Delusionality and overvalued ideas in anorexia nervosa versus body dysmorphic disorder

The two body image disorders anorexia nervosa (AN) and body dysmorphic disorder (BDD) share many similarities. Delusionality in BDD has recently gained increased attention, as the new DSM-5 criteria for BDD include an insight specifier. However, delusionalilty in AN has rarely been examined. We evaluated the delusionality of appearance-related beliefs in AN (n=19) vs. BDD (n=22) via structured interview. Participants also completed measures of disorder-specific psychopathology and body image. Compared to those with AN, individuals with BDD exhibited significantly greater delusionality on a dimensional scale (p=0.0014, d=1.07), and were more likely to meet dichotomous criteria for delusional beliefs (p=0.021, V=0.36). In AN, delusionality was associated specifically with shape concerns and drive for thinness; in BDD, delusionality was related to the severity of BDD symptoms (all p<0.05). Delusionality of appearance beliefs is present in individuals with AN, but is less pronounced than in BDD. Nevertheless, as high delusionality might predict poor treatment outcome in AN, treatment strategies that were originally developed to address delusionality in BDD might be modified for AN.     

Prevalence and clinical characteristics of body dysmorphic disorder in adolescent inpatient psychiatric patients—a pilot study

Abstract

Background: Body dysmorphic disorder (BDD) is preoccupation with perceived body defects leading to distress and impairment in social functioning. Most of adolescent BDD literature has been done on patients within the outpatient setting with prior versions of DSM with dearth of information about BDD and comorbid psychiatric conditions among adolescents within the inpatient setting.

Aims: This pilot study evaluated the prevalence rate, clinical characteristics in adolescent BDD compared to non-BDD adolescents in a psychiatric in patient setting in addition to their comorbid issues like anxiety, OCD, ADHD and substance abuse.

Methods: Forty-five consecutively admitted adolescent patients participated with 17 meeting the DSM 5 criteria for BDD while 28 did not. Patients were asked four questions designed around the DSM-5 criteria for BDD after which they were asked to complete questionnaires like BDDQ child and adolescent version, BDDM, Multiaxial Anxiety Scale for Children, Children’s Depression Inventory, Y-BOCS and Vanderbilt ADHD rating scales.

Results: Seventeen participants had BDD. Mean age of BDD patients was 13.1 while non-BDD was 12.4. Male patients with BDD were seven (41%) while female BDD patients were 10 (58.8%). Anxiety, depression, OCD and substance use disorders were common comorbid diagnoses. Majority of patients in the BDD group classified their BDD as a severe problem with more BDD, patient’s considering suicide because of their BDD.

Discussion: BDD is present in adolescents admitted in inpatient psychiatric hospital with more female patients endorsing BDD versus their male counterparts. Patients with BDD are more likely to endorse more comorbid psychiatric issues such as anxiety, OCD, ADHD and substance abuse.     

Prevalence,demographic and clinical characteristics of body dysmorphic disorder among psychiatric outpatients with mood,anxiety or somatoform disorders

Aims: To describe the prevalence, demographic and clinical characteristics of body dysmorphic disorder (BDD) compared with other psychiatric outpatients with a mood, anxiety or somatoform disorder. Method: Outpatients referred for treatment of a mood, anxiety or somatoform disorder were routinely assessed at intake. A structured interview (MINI-Plus), observer-based and self-rating instruments were administered by an independent assessor. Results: Among our sample of 3798 referred patients, 2947 patients were diagnosed with at least one DSM-IV mood, anxiety or somatoform disorder. Of these patients 1.8% (n = 54) met the diagnostic criteria for BDD. In comparison with other outpatients, patients with BDD were on average younger, less often married and were more often living alone. Highly prevalent comorbid diagnoses were major depression (in 46.3% of cases), social anxiety disorder (in 35.2% of cases) and obsessive–compulsive disorder (OCD) (in 16.7% of cases). Furthermore, patients with BDD had higher scores on the Clinical Global Impression of Severity (CGI-S) as well as lower scores on the Short Form 36 social role functioning. Conclusion: BDD is frequently associated with depression, social phobia and OCD. Patients with BDD have more distress and more impaired interpersonal functioning.     

Body dysmorphic disorder

Body dysmorphic disorder (BDD) is a relatively common disorder that consists of a distressing or impairing preoccupation with imagined or slight defects in appearance. BDD is commonly considered to be an obsessivecompulsive spectrum disorder, based on similarities it has with obsessive-compulsive disorder. It is important to recognize and appropriately treat BDD, as this disorder is associated with marked impairment in psychosocial functioning, notably poor quality of life, and high suicidality rates. In this review, we provide an overview of research findings on BDD, including its epidemiology, clinical features, course of illness, comorbidity, psychosocial functioning, and suicidality We also briefly review recent research on neural substrates and cognitive processing. Finally, we discuss treatment approaches that appear efficacious for BDD, with a focus on serotonin-reuptake inhibitors and cognitive-behavioral therapy.     

Eating disorder symptoms and comorbid psychopathology among male and female veterans

Objective

Eating disorder (ED) symptoms have gone mostly unexamined among veterans. The current study assessed rates of bulimia nervosa (BN) and binge eating disorder (BED) symptoms and diagnoses and their associations with common comorbidities among male and female veterans.

Method

Participants were US military veterans who screened positive for trauma histories and/or a probable Diagnostic and Statistical Manual of Mental Disorders 4th Edition (DSM-IV) posttraumatic stress disorder (PTSD) diagnosis (n= 499). Symptoms of PTSD were assessed using the Clinician-Administered PTSD Scale, and symptoms of EDs, mood, and substance use disorders were assessed using the Structured Clinical Interview for the DSM-IV.

Results

Lifetime rates of BN and BED diagnoses were comparable to civilian populations, and a considerable range of lifetime and current BN and BED symptoms were identified. In multivariate models, PTSD and depression severity were most consistently associated with BN and BED symptom severity, with depression most strongly associated with EDs for women.

Conclusions

Findings highlight the importance of screening for ED symptoms among male and female veterans, particularly those that present with PTSD and depression symptomatology. Future examinations of the temporal order of such relationships and the degree to which ED symptoms and associated symptoms impact veteran functioning are warranted.     

Orthorexie et troubles des conduites alimentaires : spécificité d’un profil ?

BackgroundOrthorexia is a recent identified disorder by Dr. Steve Bratman (1997) that defines obsessive concerns about healthy eating and significant impairment of functioning and suffering. An orthorexic person obsessively attaches importance to the quality of the food she eats.ObjectiveThe aim of this study is to explore the orthorexic profile linked to eating disorders (ED), body image, environmental attitudes and psychological flexibility.MethodParticipants were divided into three groups according to specific inclusion criteria: “All comers” (n = 110), “Current ED” (n = 97) and “Past ED” (n = 115). They answered a set of on line questionnaires: the French Orthorexia Scale (FOS-12), the Eating Disorders Inventory (EDI-2), the Body Esteem Scale (BES), the Acceptance and Action Questionnaire (AAQ-II), the Hospital Anxiety and Depression Scale (HADS) and the Environmental Attitudes Inventory (EAI-12).ResultsResults showed strong and significant correlations between orthorexic symptoms and several ED symptoms in the “current ED” and “past ED” groups. There are very significant differences between the three groups for the scores for orthorexia, body esteem, psychological flexibility and for all ED symptoms. However, there is no significant difference regarding environmental attitudes. The “current ED” group presents the highest scores for orthorexic symptoms and ED symptoms but the lowest scores for psychological flexibility and body esteem.ConclusionThe orthorexic profile is very close to the profile of individuals with ED. It could be a more socially and culturally acceptable rearrangement of a past ED. The other variables tested do not seem to be linked to the specificity of the orthorexic disorder. Currently, research about orthorexia is booming but there is still a lot of misunderstanding to study. Future studies will have to consider an approach in terms of psychic mechanisms and processes.     

Body image, emotions and thought control strategies in body dysmorphic disorder compared to eating disorders and healthy controls

ObjectiveA disordered body image, emotions such as shame and disgust, and intrusive thoughts are described as important and interdependent features of body dysmorphic disorder (BDD). However, research in this field is scarce and knowledge is often based on clinical observation.MethodsThe present study examined body image dimensions, emotions, and thought control strategies in individuals with: BDD (n = 31), anorexia nervosa (n = 32), bulimia nervosa (n = 34), and healthy controls (n = 33). Assessment was based on structured diagnostic interviews and self-report questionnaires.ResultsIndividuals with BDD scored higher on psychosocial and appearance manipulation dimensions of body image compared to healthy controls. Furthermore, they reported higher psychosocial impairment due to appearance than both eating disorder groups. In terms of emotions, BDD subjects reported a higher degree of negative emotions compared to healthy controls, whereas no differences were found in comparison to eating-disordered patients. Individuals with BDD reported using maladaptive strategies such as worrying and confrontation more often than healthy controls, when encountering intrusive and unwanted thoughts.ConclusionThe results indicate that individuals with BDD experience substantial psychosocial impairment due to appearance, high levels of various negative emotions and frequently use maladaptive thought control strategies.     

Body dysmorphic disorder, social anxiety and depressive symptoms in Chinese medical students

Aim

This cross-sectional study explored the prevalence of body image dissatisfaction, body dysmorphic disorder, social anxiety and depressive symptoms in first-year medical students in China.

Methods

A self-report survey design was employed, using the Body Shape Questionnaire, Swansea Muscularity Attitudes Questionnaire, Social Interaction Anxiety Scale, Dysmorphic Concern Questionnaire, Self-Rating Depression Scale and the Body Dysmorphic Disorder Questionnaire. A total of 487 first-year medical students participated.

Results

About one-third of participants (32.5%) indicated that they were very concerned about some aspect of their appearance unrelated to weight, with six female participants (1.3%) screening positive for body dysmorphic disorder (BDD). Those who displayed concern with their appearance (including those who did not screen positive for BDD) had higher levels of depressive and social anxiety symptoms than those who had no appearance concerns.     

Body dysmorphic disorder: some key issues for DSM‐V

Body dysmorphic disorder (BDD), a distressing or impairing preoccupation with an imagined or slight defect in appearance, has been described for more than a century and increasingly studied over the past several decades. This article provides a focused review of issues pertaining to BDD that are relevant to DSM‐V. The review presents a number of options and preliminary recommendations to be considered for DSM‐V: (1) Criterion A may benefit from some rewording, without changing its focus or meaning; (2) There are both advantages and disadvantages to adding a new criterion to reflect compulsive BDD behaviors; this possible addition requires further consideration; (3) A clinical significance criterion seems necessary for BDD to differentiate it from normal appearance concerns; (4) BDD and eating disorders have some overlapping features and need to be differentiated; some minor changes to DSM‐IV's criterion C are suggested; (5) BDD should not be broadened to include body integrity identity disorder (apotemnophilia) or olfactory reference syndrome; (6) There is no compelling evidence for including diagnostic features or subtypes that are specific to gender‐related, age‐related, or cultural manifestations of BDD; (7) Adding muscle dysmorphia as a specifier may have clinical utility; and (8) The ICD‐10 criteria for hypochondriacal disorder are not suitable for BDD, and there is no empirical evidence that BDD and hypochondriasis are the same disorder. The issue of how BDD's delusional variant should be classified in DSM‐V is briefly discussed and will be addressed more extensively in a separate article. Depression and Anxiety, 2010. © 2010 Wiley‐Liss, Inc.     

Eating disorder symptoms among female anxiety disorder patients in clinical practice: the importance of anxiety comorbidity assessment

This exploratory study investigated the relationship between anxiety disorders, anxiety comorbidity, and eating disorder (ED) symptoms in clinical practice, and examined the naturalistic detection of ED when diagnoses were based on the Anxiety Disorders Interview Schedule (ADIS). Two hundred and fifty-seven female patients completed an ED questionnaire and were assessed with the ADIS. Although ED frequency did not differ among anxiety disorder diagnoses, regression analyses revealed that social phobia (SP) and posttraumatic stress disorder (PTSD) accounted for unique variance in eating pathology. Questionnaire results indicated that almost 12% of patients met criteria for a possible ED. Clinicians using the ADIS evidenced good specificity but were not sensitive to detecting ED, missing 80% of possible cases. Results support possible links between ED, social phobia and PTSD and highlight the importance of assessing anxiety comorbidity when examining the relationship between ED and anxiety disorders. Results also suggest that formal screening for ED among female anxiety patients may be warranted.     

Body dysmorphic disorder and its associated psychological and psychopathological features in an Italian community sample

Objective: Body Dysmorphic Disorder (BDD) is a psychiatric condition characterized by preoccupation with perceived defects in physical appearance that are not observable or appear slight to others, along with low self-esteem, high perfectionism, and high comorbidity. Little is known about BDD prevalence and phenomenology in the Italian context, and no data are currently available on BDD prevalence using DSM-5 criteria in the Italian context. The aims of the current study were to explore the prevalence and the phenomenology of BDD and its associated psychological and psychopathological features such as self-esteem, perfectionistic traits, social anxiety, depressive, and obsessive–compulsive symptoms in a community sample.

Methods: Six hundred and fifteen community individuals completed a battery of self-report questionnaires.

Results: 10 (1.63%) individuals met DSM-5 diagnostic criteria for BDD; hair, nose and teeth were the most common areas of concern. Individuals with BDD reported also lower levels of self-esteem, more severe social anxiety symptomatology, general distress, depression and obsessive–compulsive features than people without BDD.

Conclusions: BDD is not a rare condition in the Italian context and it emerged to be associated with significant morbidity.     

Non-suicidal self-injury in patients with eating disorders: prevalence,forms, functions,and body image correlates

IntroductionMore than one third of patients with eating disorders report NSSI. Moreover, negative attitudes and feelings toward the body, body dissatisfaction, and body image disturbances have been linked to NSSI in community and clinical samples. However, there is a lack of studies exploring NSSI frequency and functions and the specific relationship between multidimensional body image dimensions and NSSI in eating disorder patients.ObjectivesFirst, we explored the frequency, types, and functions of NSSI in a sample of 226 Spanish female participants with eating disorders (ED). Second, we explored differences in NSSI and body image depending on the ED restrictive-purgative subtype; and third, we explored differences in body dissatisfaction, body image orientation, and body investment in eating disorder patients without NSSI (n = 144), with NSSI in their lifetime (n = 19), and (b) with NSSI in the previous year (n = 63).ResultsOf the overall sample, 37.1% (n = 89) had a history of self-injury during their lifetime, and 27.1% (n = 65) had self-injured in the previous year. Among the types of ongoing NSSI, the most frequent were banging (64.6%) and cutting (56.9%). Restrictive vs purgative patients differed on NSSI lifetime, Appearance Evaluation, Body Areas Satisfaction, Body Protection and Feelings and Attitudes toward the Body. Moreover, significant differences were found on Appearance Evaluation, Body Areas Satisfaction, Positive Feelings and Attitudes towards the Body, Body Protection, and Comfort with physical contact, between participants without a history of self-injury and both NSSI groups.DiscussionBody dissatisfaction and body investment have been found to be variables related to NSSI. Thus, the present study highlights the importance of working on body image in ED patients to reduce the frequency of NSSI.     

Ethnic variance between Asian and European American women in a six month prospective model of eating disorder and social anxiety symptom comorbidity

ABSTRACT

Eating disorders and social anxiety are highly comorbid. Understanding this comorbidity may improve treatment outcomes, as social anxiety can impair the ability to benefit from eating disorder treatment. The primary model of social anxiety and eating disorder comorbidity includes social appearance anxiety, high standards, and maladaptive perfectionism. In the current study, we tested for ethnic invariance between Asians (n = 82) and European Americans (n = 182) in a cross-sectional and prospective comorbidity model of social anxiety and eating disorder symptoms. Differences were found across ethnicity in eating disorder and social anxiety symptom comorbidity. Maladaptive perfectionism predicted social anxiety and eating disorder symptoms in European Americans, whereas social appearance anxiety predicted social anxiety and eating disorder symptoms in Asians. Our findings suggest that interventions for social anxiety and eating disorders in Asian populations may be improved by assessing and targeting social appearance anxiety, while maladaptive perfectionism should be targeted among European Americans.     

Body image in patients with mental disorders: Characteristics,associations with diagnosis and treatment outcome

ObjectiveDespite the increasing recognition in clinical practice of body image problems in other than appearance related mental disorders, the question remains how aspects of body image are affected in different disorders. The aim of this study was to measure body image in patients with a variety of mental disorders and to compare scores with those in the general population in order to obtain more insight in the relative disturbance of body image in the patients group compared to healthy controls. In a further exploration associations with self-reported mental health, quality of life and empowerment were established as well as the changes in body image in patients over time.Methods176 women and 91 men in regular psychiatric treatment completed the Dresden Body Image Questionnaire, the Outcome Questionnaire, the Manchester Short Assessment of Quality of Life and the Mental Health Confidence Scale. Measurements were repeated after four months.ResultsPatients with mental disorders, especially those with post-traumatic stress disorder (PTSD), scored significantly lower on body image, with large effect sizes, in comparison with the healthy controls. Scores of patients from different diagnostic groups varied across domains of body image, with body acceptance lowest in the group with eating disorders, and sexual fulfillment extremely low in PTSD. Vitality did not differ significantly between the various disorders. Gender differences were large for body acceptance and sexual fulfillment and small for vitality. Associations of body image with self-reported mental health, quality of life and empowerment were moderate to strong. After four months of treatment positive changes in body image were observed.ConclusionsNegative body image is a common problem occurring in most patients with mental disorders. Diagnosis-specific profiles emerge, with PTSD being the most affected disorder. Body acceptance and sexual fulfillment were the most differentiating aspects of body image between diagnoses. Changes in body image occur over the course of treatment.     

Understanding catastrophic worry in eating disorders: process and content characteristics

Background and objectives

The majority of people with eating disorders (ED) experience high levels of comorbid anxiety and depression, yet the maintenance processes of these in ED remain largely unknown. Worry, a defining cognitive feature and important maintenance factor of anxiety, has not been well-studied amongst people with ED. This is the first study to explore both the process and content characteristics of catastrophic worry in ED.

Methods

Twenty-nine patients with anorexia nervosa (AN), 15 patients with bulimia nervosa (BN) and 37 healthy controls (HC) completed measures assessing anxiety, depression, worry and eating disorder pathology. Catastrophic worry was assessed using the Catastrophizing Interview and catastrophic worry content was explored using qualitative Thematic Analysis.

Results

Compared to HCs, ED groups had higher levels of anxiety, depression and worry and they generated a greater number of catastrophic worry steps. Worry was further found associated with depressive symptomatology in those with ED. Worry content for the ED groups included ED themes, but also themes reflecting broader inter and intrapersonal concerns.

Limitations

The degree to which worry is driven by depressive versus anxious symptomatology remains unclear. The current study does not include an anxious or depressed control group, and results should be considered in the light of relatively small samples sizes.

Conclusion

Findings indicate that interventions that target worry processes may be a useful adjunct to treatment for those ED patients with clinical worry levels.     

Social anxiety and self-consciousness in binge eating disorder: associations with eating disorder psychopathology

ObjectiveResearch has consistently shown that anxiety disorders are common among individuals with eating disorders. Although social phobia has been found to be highly associated with eating disorders, less is known about social anxiety in individuals with binge eating disorder (BED). The present study examined associations between social anxiety and self-consciousness with body mass index (BMI) and eating disorder psychopathology in BED.MethodsParticipants were 113 overweight or obese treatment-seeking men and women with BED. Participants were administered semistructural diagnostic clinical interviews and completed a battery of self-report measures.ResultsSocial anxiety was positively and significantly correlated with shape and weight concerns and binge eating frequency. After accounting for depressive levels, social anxiety and self-consciousness accounted for significant variance in eating, shape, and weight concerns and overall eating disorder global severity scores (Eating Disorder Examination). Social anxiety also accounted for significant variance in binge eating frequency after covarying for depressive levels. Social anxiety and self-consciousness were not significantly associated with BMI or dietary restraint.DiscussionOur findings suggest that greater social anxiety and heightened self-consciousness are associated with greater eating disorder psychopathology, most notably with greater shape and weight concerns and binge eating frequency in patients with BED. Social anxiety and self-consciousness do not appear to be merely functions of excess weight, and future research should examine whether they contribute to the maintenance of binge eating and associated eating disorder psychopathology.