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

Patient reported outcome measures (PROMS) for body image in dermatology: A systematic review

INTRODUCTION

It is widely acknowledged that negative body image perception is linked to anxiety, depression, and body dysmorphic disorder. However, there is no gold standard, body image related patient reported outcome measure in use, specific for dermatologic disease, despite evidence to suggest a high prevalence of mental health problems relating to body image in this group of patients.

AIM

The aim of this study was to perform a review of body image Patient Reported Outcome Measures (PROMs) used in dermatology and to evaluate their effectiveness.

METHODS

Searches were performed in the major databases. Two investigators independently performed full text evaluation by applying an established checklist to evaluate the conceptual model, content validity, reliability, construct validity, scoring and interpretability and respondent burden.

RESULTS

Six different PROMs were identified of which only one was fully validated. There was a significant lack of patient involvement in the development of PROMs in this context.

CONCLUSIONS

We therefore encourage further research in this field to improve the quality of evidence to better understand the relationship between mental health and dermatologic disease.

Psychiatric and medical comorbidities of eating disorders: findings from a rapid review of the literature

BACKGROUND

Eating disorders (EDs) are potentially severe, complex, and life-threatening illnesses. The mortality rate of EDs is significantly elevated compared to other psychiatric conditions, primarily due to medical complications and suicide. The current rapid review aimed to summarise the literature and identify gaps in knowledge relating to any psychiatric and medical comorbidities of eating disorders.

METHODS

This paper forms part of a rapid review) series scoping the evidence base for the field of EDs, conducted to inform the Australian National Eating Disorders Research and Translation Strategy 2021-2031, funded and released by the Australian Government. ScienceDirect, PubMed and Ovid/Medline were searched for English-language studies focused on the psychiatric and medical comorbidities of EDs, published between 2009 and 2021. High-level evidence such as meta-analyses, large population studies and Randomised Control Trials were prioritised.

RESULTS

A total of 202 studies were included in this review, with 58% pertaining to psychiatric comorbidities and 42% to medical comorbidities. For EDs in general, the most prevalent psychiatric comorbidities were anxiety (up to 62%), mood (up to 54%) and substance use and post-traumatic stress disorders (similar comorbidity rates up to 27%). The review also noted associations between specific EDs and non-suicidal self-injury, personality disorders, and neurodevelopmental disorders. EDs were complicated by medical comorbidities across the neuroendocrine, skeletal, nutritional, gastrointestinal, dental, and reproductive systems. Medical comorbidities can precede, occur alongside or emerge as a complication of the ED.

CONCLUSIONS

This review provides a thorough overview of the comorbid psychiatric and medical conditions co-occurring with EDs. High psychiatric and medical comorbidity rates were observed in people with EDs, with comorbidities contributing to increased ED symptom severity, maintenance of some ED behaviours, and poorer functioning as well as treatment outcomes. Early identification and management of psychiatric and medical comorbidities in people with an ED may improve response to treatment and overall outcomes.

Broad and Narrow Transdiagnostic Risk Factors in Eating Disorders: A Preliminary Study on an Italian Clinical Sample

Eating disorders are multifaceted psychopathologies and the transdiagnostic approach is currently considered a useful framework to understand their complexity. This preliminary study aimed to investigate both broad (i.e., intolerance of uncertainty and emotion dysregulation) and narrow (i.e., extreme body dissatisfaction) transdiagnostic risk factors underlying eating disorders. 50 Italian female patients seeking treatment for an eating disorder were involved (M_age = 31.6 years ± 12.8, 18–65). They completed self-report measures assessing emotion regulation difficulties, intolerance of uncertainty, extreme body dissatisfaction, general psychological distress, and eating disorder symptomatology. To explore whether the abovementioned transdiagnostic factors predicted patients’ psychological distress and eating disorder symptoms, two linear regressions were performed. Emotion dysregulation emerged as the only significant predictor of distress, while extreme body dissatisfaction was the only significant predictor of overall eating disorder symptomatology. Then, to analyze the differences between patients with anorexia nervosa and bulimia nervosa in intolerance of uncertainty and emotion regulation problems, t-tests were conducted. The two groups differed significantly in intolerance of uncertainty levels only, with higher scores obtained by patients with anorexia nervosa. Overall, our findings suggest that emotion dysregulation and extreme body dissatisfaction may be relevant constructs in eating disorders in general, while intolerance of uncertainty may be more involved in restrictive eating disorders. The clinical implications of such results are discussed.

Subjective Experience of Antidepressant Prescription Among Adolescents With Anorexia Nervosa

INTRODUCTION

Major depressive disorder is considered the most common comorbidity of anorexianervosa in adolescence. Some evidence argues against antidepressant use in this population. Moreover, the fear of being threatened with autonomy and of becoming dependent specific to this adolescent population and at the very core of the anorexic disease, make the proposal of such a treatment difficult to accept. This qualitative research aimed to explore the perspectives of view of adolescents with anorexia nervosa about antidepressants.

METHODS

We conducted interviews with adolescents suffering from anorexia nervosa who had been treated with an antidepressant agent during their inpatient or outpatient care at Cochin Hospital. Adolescents were chosen by convenience sampling. Both verbal and written questions were asked to elicit their lived experiences. Interpretative Phenomenological Analysis was used to examine the data.

RESULTS

Fifteen adolescents (13 girls and two boys) were interviewed. We have reached total data saturation. The analysis found two meta-themes, each with two separate themes. (I) Reactions to the proposal of antidepressant with (i) an opposition phase (about the existence of depressive symptoms and about negative preconceptions) and (ii) need to share with family and other teenagers. (II) Reactions to antidepressant use with (iii) ambivalence and an initial perception of coercion, and (iv) effects of antidepressants (psychological effects, effects on the body and on anorexia nervosa and effects perceived through the eyes of others).

DISCUSSION

Despite positive effects, ambivalence toward the treatment remained present throughout the interviews: these adolescents still worry greatly about loss of control and weight gain. Depression as comorbidity seems to be entangled in the denial of disease, cognitive distortion and acquired fearlessness specific to AN. Its existence in adolescence can uncover transgenerational issues, sometimes previously hidden. An orodispersible/drinkable form of antidepressants would facilitate adherence to treatment in this specific population. The intervention of a "patient-expert" could reduce adolescents' anxiety about loss of control. A latency period seems necessary to allow them to understand the prescription at their own level and in the complexity of their anorexic illness.

Facing an eating disorder: A case of body dysmorphic disorder and avoidant/restrictive food intake disorder

Eating disorders can be notoriously difficult to diagnose and treat. This patient is an 18-year-old female who presents to care severely underweight and notably cachexic. For a number of years, she had experienced depressive symptoms, anxiety, and continued loss of appetite. She denied purposefully restricting foods, recognized that she was thin, and denied a fear of gaining weight. She was admitted to a disordered eating unit for refeeding and during her inpatient stay disclosed that she had a long-standing “hatred of face.” Ultimately, she received the diagnoses of avoidant/restrictive food intake disorder and body dysmorphic disorder. This case highlights the importance of differentiating body dysmorphia, seen in body dysmorphic disorder, and distorted body image, as seen in anorexia nervosa. This differentiation is significant as the treatment approaches to these distinct diagnoses are not the same.

The relationship between body dysmorphic disorder symptoms and 'not just right' experiences in a sample of individuals seeking cosmetic surgery and aesthetic medicine procedures

BACKGROUND

Body dysmorphic disorder (BDD) is characterized by concerns for perceived defects in physical appearance that appear to others as mild or unobservable. Individuals with BDD frequently refer concerns with their physical appearance being 'not right' (not just right experiences; NJREs), and BDD-related behaviours may be performed until their appearance is perceived as 'right'. The aim of the study was to explore the relationship between BDD and NJREs in cosmetic surgery and aesthetic medicine settings.

METHODS

Individuals requesting cosmetic procedures with BDD symptoms (BDD-symptoms group; n = 24), without BDD symptoms (cosmetic intervention [CI] group; n = 45), and individuals that have never required these procedures (no cosmetic intervention [NCI] group; n = 53) entered the study.

RESULTS

Results showed a greater number of past-month NJREs, higher NJREs severity, higher drive for thinness, and greater general distress in the BDD-symptoms group. Pertaining to features associated with NJREs (perfectionism and obsessive-compulsive disorder symptoms) and ED core features, the BDD-symptoms group scored higher only with respect to NCI. Regression analyses showed that BDD symptoms were predicted by age, NJREs severity, and drive for thinness above and beyond general distress, perfectionism, obsessive-compulsive disorder symptoms, bulimia, and body dissatisfaction related to weight and shape in the BDD-Symptoms group (in comparison with the CI and NCI groups).

CONCLUSIONS

NJREs may represent a potential vulnerability factor for BDD symptoms in cosmetic settings.

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.

Sociocultural Attitudes towards Appearance, Self-Esteem and Symptoms of Body-Dysmorphic Disorders among Young Adults

Background: Beauty and an attractive body shape are particularly important during early adulthood, as both are related to greater mating success, positive social feedback, and higher self-esteem. The media may further influence common features of beauty. We tested whether higher body-dysmorphic disorder (BDD) scores were associated with sociocultural attitudes towards appearance. Additionally, we expected that a link between higher BDD scores and higher perceived media pressure would be mediated by lower self-esteem (SE). Method: 350 young Iranian adults (mean age: 24.17 years; 76.9% females) took part in the study. Participants completed questionnaires covering sociodemographic data, sociocultural attitudes towards appearances, and SE, while experts rated participants for symptoms of body dysmorphic disorders. Results: Higher BDD scores were associated with higher scores for sociocultural attitudes towards appearance, while SE was not associated with BDD or sociocultural attitudes towards appearance. Higher scores for sociocultural attitudes towards appearance and media pressure predicted higher BDD scores, while SE had no influence. Conclusion: Among young Iranian adults, sociocultural attitudes towards appearances and BDD scores, as rated by experts’, were related, while SE was not. The shared variance between symptoms of BDD and sociocultural attitudes towards appearance was low, suggesting that other factors such as mating and career concerns together with social feedback might be more important in explaining symptoms of body dysmorphic disorders.

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.

Direct comparisons of anorexia nervosa and body dysmorphic disorder: A systematic review

Anorexia nervosa (AN) and body dysmorphic disorder (BDD) are serious psychiatric conditions, both of which are associated with a disturbance of body image. The aim of this paper was to review those studies that have directly compared groups of individuals with AN and BDD, to determine similarities and differences in presentation between the two conditions. The literature was searched to September 2018, and studies were included if they were English language, empirical research papers published in peer-reviewed journals, specifically comparing AN and BDD patients. Fifteen relevant studies were identified. The results suggested that individuals with AN and BDD share a number of similarities, including their degree of body dissatisfaction. Differences between the conditions included primary concerns with body shape and weight in AN, and much more diffuse concerns (but predominantly the face) in BDD. The small number of studies, along with the limited replication of results emphasises the need for greater research in this area. However, the studies undertaken to date highlight the high degree of overlap between AN and BDD and suggests that the conditions may represent similar body image disorders. This has implications for the nosological status of AN and BDD.

Dysmorphic concern in anorexia nervosa: Implications for recovery

Body image disturbance ('dysmorphic concern') is a key diagnostic criterion for anorexia nervosa (AN). While dysmorphic concern has been described as a relapse predictor, relatively little is understood about the prevalence in AN, and the consequences upon wellbeing. The present study examined the rates of dysmorphic concern in a sample of treatment-seeking adults with AN (N = 39), and explored the associations with general mental health, disability and eating disorder symptoms. The majority of participants (61.5%) had clinically significant levels of dysmorphic concern. Furthermore, higher dysmorphic concern scores were associated with increased symptoms of anxiety, depression and eating disorder symptomatology. There was also a trend towards associations between dysmorphic concern and age of onset and stages of change (pre-contemplation, contemplation, preparation, action, maintenance), although replication is required. These findings suggest that strategies which specifically address body image distortions should be a key feature of treatment for anorexia nervosa to support long-term recovery and wellbeing.