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.     

Clinical and subclinical body dysmorphic disorder

Background The aim of the study was to define the main demographic and clinical characteristics of Body Dysmorphic Disorder (BDD) and subclinical BDD (sBDD) in a sample derived by a screening survey done on a population of individuals referring to aesthetical medicine centers. Method 487 subjects referring to hospital centers for aesthetical medicine were administered the SCID-I and the Yale-Brown Obsessive-Compulsive Scale adapted for BDD (BDD-YBOCS). The sample was thus sub-divided in three sub-samples: 1) BDD, 2) sub-clinical BDD, and 3) controls. The main demographic and clinical variables were considered and compared between the BDD and the sBDD samples. Results As previously reported, the prevalence of BDD and sBDD was 6.3 % and 18.4 %, respectively. The most frequent comorbid diagnosis in both BDD and sBDD patients and their relatives was Obsessive-Compulsive Disorder (OCD). A higher severity of symptoms was found in male BDD patients, while no gender-related differences were found in the sBDD group. Suicidal ideation was found in 12.1 % of the sBDD and in 49.7 % of the BDD patients. Conclusions These results support the hypothesis of BDD and sBDD belonging to the OCD spectrum, and appear to advise long-term follow-up studies on the course and the prognosis of sBDD. Received: 5. December 2000 / Accepted: 21. March 2001     

躯体变形障碍合并边缘型人格障碍的访谈与治疗

咨客,女性,25岁,经常感觉眼睛变小,反复为此纠结。个人情绪不稳定、易激动,在人际关系方面存在问题。在本次咨询中患者被诊断为躯体变形障碍合并边缘型人格障碍,建议采用生物-心理-社会的综合干预模式治疗。鼓励咨客规律运动,服用选择性5-羟色胺再摄取抑制剂(SSRIs)和第二代抗精神病药物联合治疗;采用辩证行为治疗(DBT)调整咨客认知、稳定情绪、改善人际技能;工作上建议选择人际压力小的工作环境,如影像学类临床辅助科室。     

Status of body dysmorphic disorder in Argentina

Although body dysmorphic disorder (BDD) has received recent attention, it remains misunderstood and under-studied. The Argentine population seeks out plastic surgery at a disproportionate rate and exhibits high rates of preoccupation with bodily dissatisfaction, yet BDD is unrecognized and research is limited. The current study describes the prevalence, quality of life, and presentation style of BDD in depressed adolescents, as depression is the most common symptom for which adolescents seek treatment in Argentina. Twenty-five depressed adolescents and 85 non-depressed students were initially assessed for depression and BDD and subdivided depending on BDD status. Participants were assessed on various constructs including obsessions and compulsions, overvalued ideas, and overall level of impairment. A 2 × 2 factorial design was employed, and multivariate analysis of variance (MANOVA) was used to analyze the data. Significant main effects were observed for all dependent measures (BDI, OVIS, YBOCS, and Sheehan Disability Scale) for depressed vs. non-depressed participants and BDD status; significant interactions were observed between independent variables for all dependent measures. Depressed adolescents had significantly higher scores on the YBOCS-BDD, OVIS, BDI, and the Sheehan Disability Scale compared to non-depressed participants; furthermore, individuals reporting BDD symptoms reported significantly higher scores on the YBOCS-BDD, OVIS, BDI, and Sheehan Disability Scale. Significant interactions are discussed according to BDD status and depression on dependent measures. Patients with BDD have poor quality of life and present with anxiety and depression, yet it still remains underdiagnosed.     

躯体变形障碍的临床访谈与治疗

本文对躯体变形障碍的咨客进行案例报告,目的是提高精神科临床工作者的临床访谈技巧、诊疗思路及治疗方案的制定。咨客17岁,未婚男性,因为对自己的相貌不满意、自卑来访。咨客在学习环境转换后,出现对外貌的过度关注,伴情绪差。咨客被诊断为躯体变形障碍。建议采用生物-心理-社会综合干预的方法,生物治疗方面,给予舍曲林联合喹硫平,改善咨客的焦虑抑郁情绪和认知。心理治疗方面,采用正念减压和认知行为治疗,帮助咨客学会放松,纠正认知偏差。社会资源方面,鼓励家属积极关注咨客的优点,加强校园内课业管理,促进咨客自信心的发展。     

Prevalence of body dysmorphic disorder in a German psychiatric inpatient sample

Body dysmorphic disorder (BDD) is a distressing or impairing preoccupation with an imagined or slight defect in appearance. Only a few studies have examined BDD prevalence in psychiatric settings. Prevalence rates vary widely and most studies have been conducted in outpatient samples. In the current study, we examined 155 adult psychiatric inpatients. Diagnostic criteria of BDD were assessed with the BDD module of the Structured Clinical Interview for DSM-IV. The prevalence of lifetime BDD was 2.6% (95% CI = 0.1-5.1%). Currently 1.9% of the patients suffered from BDD (95% CI = 0.0-4.0%). None of these patients were diagnosed with BDD on admission or during hospitalization. The BDD rates found in this study are considerably lower than lifetime and current prevalence rates reported by two other studies conducted in adult psychiatric inpatient settings ( [Grant et al., 2001] and [Conroy et al., 2008]). The differences may be explained by divergent sample compositions and variation in diagnostic measures. The findings of the current study underline the need for further studies examining BDD prevalence in psychiatric settings and suggest using a combination of screening questionnaire and follow-up interview to diagnose BDD.     

Pathological skin picking in individuals with body dysmorphic disorder

OBJECTIVE: The objective of this study was to examine the prevalence and clinical correlates of pathological skin picking (PSP) in a large sample of individuals with body dysmorphic disorder (BDD). METHOD: One hundred seventy-six individuals with BDD (71.0% women; mean age, 32.5+/-12.3 years) were assessed with respect to comorbidity, BDD severity, delusionality (insight), quality of life and social/occupational functioning, using reliable and valid measures. All variables were compared in BDD subjects with and without lifetime PSP. RESULTS: About 44.9% of subjects reported lifetime PSP, and 36.9% reported current PSP secondary to BDD. BDD subjects with PSP were more likely to be female, to have skin preoccupations, to have comorbid trichotillomania or a personality disorder, to camouflage with makeup and to seek and receive nonpsychiatric (e.g., dermatological) treatment for their skin preoccupations. CONCLUSION: There is a high prevalence of PSP among individuals with BDD, and clinicians should be aware of the clinical correlates of this problematic behavior.     

Neurological soft signs in obsessive compulsive disorder with good and poor insight

Objective

Obsessive compulsive disorder (OCD) is a clinically heterogeneous disorder; OCD with poor insight has been suggested to be a specific clinical subtype. Neurological soft signs (NSSs) may be helpful to identify the specific subtypes of OCD patients.

Methods

In the present study, we aimed to compare OCD patients with poor insight with OCD patients having good insight, and healthy individuals. Sixty-four OCD patients (38 with good insight and 26 with poor insight), and 32 healthy subjects were enrolled in the present study. The Overvalued Ideas Scale (OVIS) was used to determine OCD patients with poor insight. NSSs were assessed by using the Neurological Evaluation Scale (NES).

Results

Two OCD groups had significantly higher total NES scores compared to controls (p = .000). Compared to healthy controls, OCD patients with poor insight performed significantly worse on all NES subscales, and they had significantly more NSSs on motor coordination, and sensory integration subscales compared to the OCD with good insight group.

Conclusion

Our results suggested that OCD patients with poor insight exhibit more extensive neurodevelopmental impairments compared to OCD patients with good insight.     

Body-related cognitions,affect and post-event processing in body dysmorphic disorder

Background and objectives

Cognitive behavioural models postulate that individuals with BDD engage in negative appearance-related appraisals and affect. External representations of one's appearance are thought to activate a specific mode of processing characterized by increased self-focused attention and an activation of negative appraisals and affect.

Methods

The present study used a think-aloud approach including an in vivo body exposure to examine body-related cognitions and affect in individuals with BDD (n = 30), as compared to individuals with major depression (n = 30) and healthy controls (n = 30). Participants were instructed to think aloud during baseline, exposure and follow-up trials.

Results

Individuals with BDD verbalized more body-related and more negative body-related cognitions during all trials and reported higher degrees of negative affect than both control groups. A weaker increase of positive body-related cognitions during exposure, a stronger increase of sadness and anger after exposure and higher levels of post-event processing, were specific processes in individuals with BDD.

Limitations

Individuals with major depression were not excluded from the BDD group. This is associated with a reduction of internal validity, as the two clinical groups are somewhat interwoven. Key findings need to be replicated.

Conclusion

The findings indicate that outcomes such as negative appearance-related cognitions and affect are specific to individuals with BDD. An external representation of one's appearance activates a specific mode of processing in BDD, manifesting itself in the absence of positive body-related cognitions, increased anger and sadness, and high levels of post-event processing. These specific processes may contribute toward maintenance of BDD psychopathology.     

Inverted face processing in body dysmorphic disorder

Individuals with body dysmorphic disorder (BDD) are preoccupied with perceived defects in appearance. Preliminary evidence suggests abnormalities in global and local visual information processing. The objective of this study was to compare global and local processing in BDD subjects and healthy controls by testing the face inversion effect, in which inverted (upside-down) faces are recognized more slowly and less accurately relative to upright faces. Eighteen medication-free subjects with BDD and 17 matched, healthy controls performed a recognition task with sets of upright and inverted faces on a computer screen that were either presented for short duration (500 ms) or long duration (5000 ms). Response time and accuracy rates were analyzed using linear and logistic mixed effects models, respectively. Results indicated that the inversion effect for response time was smaller in BDD subjects than controls during the long duration stimuli, but was not significantly different during the short duration stimuli. Inversion effect on accuracy rates did not differ significantly between groups during either of the two durations. Lesser inversion effect in BDD subjects may be due to greater detail-oriented and piecemeal processing for long duration stimuli. Similar results between groups for short duration stimuli suggest that they may be normally engaging configural and holistic processing for brief presentations. Abnormal visual information processing in BDD may contribute to distorted perception of appearance; this may not be limited to their own faces, but to others’ faces as well.     

Psychological treatment of social anxiety disorder improves body dysmorphic concerns

Social anxiety disorder and body dysmorphic disorder are considered nosologically distinct disorders. In contrast, some cognitive models suggest that social anxiety disorder and body dysmorphic disorder share similar cognitive maintenance factors. The aim of this study was to examine the effects of psychological treatments for social anxiety disorder on body dysmorphic disorder concerns. In Study 1, we found that 12 weekly group sessions of cognitive-behavioral therapy led to significant decreases in body dysmorphic symptom severity. In Study 2, we found that an attention retraining intervention for social anxiety disorder was associated with a reduction in body dysmorphic concerns, compared to a placebo control condition. These findings support the notion that psychological treatments for individuals with primary social anxiety disorder improve co-occurring body dysmorphic disorder symptoms.     

Facial affect recognition in body dysmorphic disorder versus obsessive-compulsive disorder: An eye-tracking study

BackgroundBody dysmorphic disorder (BDD) is characterised by repetitive behaviours and/or mental acts occurring in response to preoccupations with perceived defects or flaws in physical appearance (American Psychiatric Association, 2013). This study aimed to investigate facial affect recognition in BDD using an integrated eye-tracking paradigm.MethodParticipants were 21 BDD patients, 19 obsessive-compulsive disorder (OCD) patients and 21 healthy controls (HC), who were age-, sex-, and IQ-matched. Stimuli were from the Pictures of Facial Affect (Ekman & Friesen, 1975), and outcome measures were affect recognition accuracy as well as spatial and temporal scanpath parameters.ResultsRelative to OCD and HC groups, BDD patients demonstrated significantly poorer facial affect perception and an angry recognition bias. An atypical scanning strategy encompassing significantly more blinks, fewer fixations of extended mean durations, higher mean saccade amplitudes, and less visual attention devoted to salient facial features was found.ConclusionsPatients with BDD were substantially impaired in the scanning of faces, and unable to extract affect-related information, likely indicating deficits in basic perceptual operations.     

Delusional versus nondelusional body dysmorphic disorder: clinical features and course of illness

DSM-IV's classification of body dysmorphic disorder (BDD) is controversial. Whereas BDD is classified as a somatoform disorder, its delusional variant is classified as a psychotic disorder. However, the relationship between these BDD variants has received little investigation. In this study, we compared BDD's delusional and nondelusional variants in 191 subjects using reliable and valid measures that assessed a variety of domains. Subjects with delusional BDD were similar to those with nondelusional BDD in terms of most variables, including most demographic features, BDD characteristics, most measures of functional impairment and quality of life, comorbidity, and family history. Delusional and nondelusional subjects also had a similar probability of remitting from BDD over 1 year of prospective follow-up. However, delusional subjects had significantly lower educational attainment, were more likely to have attempted suicide, had poorer social functioning on several measures, were more likely to have drug abuse or dependence, were less likely to currently be receiving mental health treatment, and had more severe BDD symptoms. However, when controlling for BDD symptom severity, the two groups differed only in terms of educational attainment. These findings indicate that BDD's delusional and nondelusional forms have many more similarities than differences, although on several measures delusional subjects evidenced greater morbidity, which appeared accounted for by their more severe BDD symptoms. Thus, these findings offer some support for the hypothesis that these two BDD variants may constitute the same disorder. Additional studies are needed to examine this issue, which may have relevance for other disorders with both delusional and nondelusional variants in DSM.     

Functional impairment in body dysmorphic disorder: a prospective, follow-up study

Cross-sectional/retrospective studies indicate that individuals with body dysmorphic disorder (BDD) have markedly impaired psychosocial functioning. However, no study has prospectively examined functioning in BDD. In this study, which is to our knowledge the first prospective study of the course of BDD, psychosocial functioning was assessed at baseline and over 1–3 years (mean = 2.7 ± 0.9 years) of follow-up with the Global Assessment of Functioning scale (GAF), Social and Occupational Functioning Scale (SOFAS), and LIFE-RIFT (Range of Impaired Functioning Tool). Psychosocial functioning was poor during the follow-up period. Functioning remained stably poor over time on the SOFAS and LIFE-RIFT, although there was a trend for a gradual and slight improvement on the GAF over time. The cumulative probability of attaining functional remission on the GAF (score > 70 for at least 2 consecutive months) during the follow-up period was only 5.7%. On the SOFAS, the cumulative probability of attaining functional remission (score > 70 for at least 2 consecutive months) was 10.6%. BDD severity significantly predicted functioning on the GAF (p = 0.0012), SOFAS (p = 0.0017), and LIFE-RIFT (p = 0.0015). A trend for a time-by-BDD severity interaction was found on the GAF (p = 0.033) but not the SOFAS or LIFE-RIFT. More delusional BDD symptoms also predicted poorer functioning on all measures, although this finding was no longer significant when controlling for BDD severity. Functioning was not predicted, however, by age, gender, BDD duration, or a personality disorder. In conclusion, psychosocial functioning was poor over time, and few subjects attained functional remission. Greater BDD severity predicted poorer functioning.     

Associations in the longitudinal course of body dysmorphic disorder with major depression, obsessive-compulsive disorder, and social phobia

Body dysmorphic disorder (BDD) is an impairing and relatively common disorder that has high comorbidity with certain Axis I disorders. However, the longitudinal associations between BDD and comorbid disorders have not previously been examined. Such information may shed light on the nature of BDD's relationship to putative "near-neighbor" disorders, such as major depression, obsessive-compulsive disorder (OCD), and social phobia. This study examined time-varying associations between BDD and these comorbid disorders in 161 participants over 1-3 years of follow-up in the first prospective longitudinal study of the course of BDD. We found that BDD had significant longitudinal associations with major depression--that is, change in the status of BDD and major depression was closely linked in time, with improvement in major depression predicting BDD remission, and, conversely, improvement in BDD predicting depression remission. We also found that improvement in OCD predicted BDD remission, but that BDD improvement did not predict OCD remission. No significant longitudinal associations were found for BDD and social phobia (although the results for analyses of OCD and social phobia were less numerically stable). These findings suggest (but do not prove) that BDD may be etiologically linked to major depression and OCD, i.e., that BDD may be a member of both the putative OCD spectrum and the affective spectrum. However, BDD does not appear to simply be a symptom of these comorbid disorders, as BDD symptoms persisted in a sizable proportion of subjects who remitted from these comorbid disorders. Additional studies are needed to elucidate the nature of BDD's relationship to commonly co-occurring disorders, as this issue has important theoretical and clinical implications.     

'Everybody looks at my pubic bone'--a case report of an adolescent patient with body dysmorphic disorder

OBJECTIVE: Body dysmorphic disorder (BDD) was described for the first time more than 100 years ago, but it is still unknown to many clinicians. Although the onset usually occurs during adolescence, BDD has received little attention in the adolescent psychiatric literature. METHOD: The case and treatment of a 16-year-old female patient is described. RESULTS: The patient, suffering from the overvalued belief of a dislocated pubic bone, a comorbid mild depressive episode, BDD associated rituals and social avoidance, was treated successfully with a combination of exposure and response prevention and 125 mg/day of doxepine. CONCLUSION: If BDD is diagnosed early in the course and treated appropriately, it is possible to obtain a satisfying outcome.     

Emotion recognition bias for contempt and anger in body dysmorphic disorder

Body dysmorphic disorder (BDD) patients are preoccupied with imagined defects or flaws in appearance (e.g., size or shape of nose). They are afraid of negative evaluations by others and often suffer significant morbidity including hospitalization and suicide attempts. Many patients experience ideas of reference, e.g., they often believe others take special notice of their "flaw". Facial expressions play an important role in conveying negative or positive feelings, and sympathy or rejection. In this study, we investigated emotion recognition deficits in 18 BDD patients and 18 healthy controls. Participants were presented with two questionnaires accompanying facial photographs. One questionnaire included self-referent scenarios ("Imagine that the bank teller is looking at you. What is his facial expression like?"), whereas the other one included other-referent scenarios ("Imagine that the bank teller is looking at a friend of yours," etc.), and participants were asked to identify the corresponding emotion (e.g., anger, contempt, neutral, or surprise). Overall, BDD patients, relative to controls, had difficulty identifying emotional expressions in self-referent scenarios. They misinterpreted more expressions as contemptuous and angry in self-referent scenarios than did controls. However, they did not have significantly more difficulties identifying emotional expressions in other-referent scenarios than controls. Thus, poor insight and ideas of reference, common in BDD, might be related to a bias for misinterpreting other people's emotional expressions as negative. Perceiving others as rejecting might reinforce concerns about one's personal perceived ugliness and social desirability.     

因自杀行为而就诊的躯体变形障碍1例报告

概述：对治疗伴自杀行为的躯体变形障碍(body dysmorphic disorder, BDD)的病例报道较少。本文报道了一位患有BDD的19岁男性患者,两年来认为自己面部变丑,这一信念逐渐加重,几乎达妄想程度。然而,他最初被误诊为抑郁障碍,部分原因是他企图自杀,当时存在抑郁症状和社会退缩。后来经证实,这些症状是继发于BDD的。经过8周住院治疗,采用氟西汀和认知行为治疗相结合,患者的症状彻底改善,社会功能也恢复正常。这一病例提醒我们,自杀行为和意念有多方面原因;为了避免误诊和不恰当的治疗,临床医生只有在排除其它可能的原因后才能推断自杀行为和意念是抑郁症的直接结果。本文也讨论了自1886年Enrico Morselli首度报道BDD后,在理解BDD和BDD的诊断标准上的诸多变化。     

Psychosis in body dysmorphic disorder

Body dysmorphic disorder (BDD) has both psychotic and nonpsychotic variants, which are classified as separate disorders in DSM-IV (delusional disorder and a somatoform disorder). Despite their separate classification, available evidence indicates that BDD's delusional and nondelusional forms have many similarities (although the delusional variant appears more severe), suggesting that they may actually be the same disorder, characterized by a spectrum of insight. And contrary to what might be expected, BDD's delusional form, although classified as a psychotic disorder, appears to respond to serotonin-reuptake inhibitors alone. These and other data suggest that a dimensional view of psychosis (in particular, delusions) in these disorders may be more accurate than DSM's current categorical view. A dimensional model might also facilitate more consistent and accurate classification of other disorders that are likely characterized by a spectrum of insight, such as obsessive compulsive disorder, hypochondriasis, and anorexia nervosa. Further research is needed to better understand these classification issues, which likely have treatment implications.     

The role of obsessive beliefs in patients with major depressive disorder

Aim. The aim of this study is to evaluate the differences in obsessional beliefs between patients with major depressive disorder (MDD) and matched healthy controls using the obsessive-beliefs questionnaire (OBQ). Methods. The study sample included 74 outpatients with MDD and 74 healthy subjects. The two groups were matched for age, gender, and education level. The diagnoses were based on the Diagnostic and Statistical Manual of Mental Disorder (DSM-IV). The severity of depression was measured with the Hamilton Depression Rating Scale (HAM-D). All participants filled out the 44-item OBQ. Results. The total and subscale OBQ scores [Responsibility/Threat Estimation (RT), Perfectionism/Certainly (PC), and Importance/Control of Thoughts (ICT)], were significantly higher in patients with MDD than those of the control group. There was a positive correlation between HAM-D scores and the OBQ subscale scores (RT, PC, and ICT) in the patients. Conclusion. Obsessional beliefs appear to be related to MDD.