A systematic review of visual processing and associated treatments in body dysmorphic disorder

Visual Perceptual Processing Abnormalities in Body Dysmorphic Disorder

Phenomenological observations of individuals with body dysmorphic disorder (BDD), coupled with evidence from neuropsychological, psychophysical, and neuroimaging studies, support a model of aberrant visual perception characterized by deficient global/holistic, enhanced detail/local processing, and selective visual-attentional biases. These features may contribute to the core symptomatology of distorted perception of their appearance, in addition to misinterpretation of others' facial expressions and poor insight regarding their misperceived appearance defects. Insights from visual processing studies can contribute to the development of novel interventions, such as perceptual retraining and non-invasive neuromodulation. However, much remains to be understood about visual perception in BDD. Future research should leverage brain imaging modalities with high temporal resolutions and employ study designs that induce conflicts in multisensory integration, thereby advancing our mechanistic understanding of distorted visual perception observed in BDD.

Disturbed interoception in body dysmorphic disorder: A framework for future research

Body dysmorphic disorder is a severe psychiatric condition characterised by a preoccupation with a perceived appearance flaw or flaws that are typically not observable to others. Although significant advances in understanding the disorder have been made in the past decade, current explanations focus on cognitive, behavioural and visual perceptual disturbances that contribute to the disorder. Such a focus does not consider how perception of the internal body or interoception may be involved, despite (1) clinical observations of disturbed perception of the body in body dysmorphic disorder and (2) disturbed interoception being increasingly recognised as a transdiagnostic factor underlying a wide range of psychopathologies. In this paper, we use an existing model of hierarchical brain function and neural (predictive) processing to propose that body dysmorphic disorder involves defective interoception, with perceived appearance flaws being the result of 'interoceptive prediction errors' that cause body parts to be experienced as 'not just right'. We aim to provide a framework for interoceptive research into body dysmorphic disorder, and outline areas for future research.

A hierarchy of visual processing deficits in body dysmorphic disorder: a conceptual review and empirical investigation

OBJECTIVE

Abnormal visual processing has been proposed as a mechanism underlying excessive focus on minor appearance flaws in body dysmorphic disorder (BDD). Existing BDD research has not differentiated the various stages of face processing (featural, first-order configural, holistic and second-order configural) that are required for higher-order processes such as emotion recognition. This study investigated a hierarchical visual processing model to examine the nature of abnormalities in face processing in BDD.

METHOD

Thirty BDD participants and 27 healthy controls completed the Navon task, a featural and configural face processing task and a facial emotion labelling task.

RESULTS

BDD participants performed similarly to controls when processing global and local non-face stimuli on the Navon task, when detecting subtle changes in the features and spacing of a target face, and when labelling emotional faces. However, BDD participants displayed poorer performance when viewing inverted faces, indicating difficulties in configural processing.

CONCLUSIONS

The findings only partially support prior work. However, synthesis of results with previous findings indicates that heterogenous task methodologies may contribute to inconsistent findings. Recommendations are provided regarding the task parameters that appear most sensitive to abnormalities in BDD.

Cytoarchitectonically Defined Volumes of Early Extrastriate Visual Cortex in Unmedicated Adults With Body Dysmorphic Disorder

BACKGROUND

Individuals with body dysmorphic disorder (BDD) misperceive that they have prominent defects in their appearance, resulting in preoccupations, time-consuming rituals, and distress. Previous neuroimaging studies have found abnormal activation patterns in the extrastriate visual cortex, which may underlie experiences of distorted perception of appearance. Correspondingly, we investigated gray matter volumes in individuals with BDD in the early extrastriate visual cortex using cytoarchitectonically defined maps that were previously derived from postmortem brains.

METHODS

We analyzed T1-weighted magnetic resonance imaging data from 133 unmedicated male and female participants (BDD: n = 65; healthy control subjects: n = 68). We used cytoarchitectonically defined probability maps for the early extrastriate cortex, consisting of areas corresponding to V2, V3d, V3v/VP, V3a, and V4v. Gray matter volumes were compared between groups, supplemented by testing associations with clinical symptoms.

RESULTS

The BDD group exhibited significantly larger gray matter volumes in the left and right early extrastriate cortex. Region-specific follow-up analyses revealed multiple subregions showing larger volumes in BDD, significant in the left V4v. There were no significant associations after corrections for multiple comparisons between gray matter volumes in early extrastriate cortex and BDD symptoms, comorbid symptoms, or duration of illness.

CONCLUSIONS

Greater volumes of the early extrastriate visual cortex were evident in those with BDD, which aligns with outcomes of prior studies revealing BDD-specific functional abnormalities in these regions. Enlarged volumes of the extrastriate cortex in BDD might manifest during neurodevelopment, which could predispose individuals to aberrant visual perception and contribute to the core phenotype of distortion of perception for appearance.

Mechanisms of cognitive behavioral therapy vs. supportive psychotherapy in body dysmorphic disorder: An exploratory mediation analysis

Body dysmorphic disorder (BDD) is common, severe, and often chronic. Cognitive behavioral therapy (CBT) is the first-line psychosocial treatment for BDD, with well-established efficacy. However, some patients do not improve with CBT, and little is known about how CBT confers its effects. Neurocognitive processes have been implicated in the etiology and maintenance of BDD and are targeted by CBT-BDD treatment components. Yet, the malleability of these factors in BDD, and their potential role in mediating symptom improvement, are not well understood. Understanding how treatment works could help optimize treatment outcomes. In this secondary data analysis of a randomized clinical trial of CBT vs. supportive psychotherapy (SPT) in BDD (n = 120), we examined whether treatment-related changes in detail processing (Rey-Osterrieth Complex Figure test), maladaptive appearance beliefs (Appearance Schemas Inventory-Revised), and emotion recognition (Emotion Recognition Task) mediated treatment outcome. All constructs improved over time and were associated with symptom improvement. CBT was associated with greater improvements in maladaptive beliefs than SPT. None of the variables examined mediated symptom improvement. Findings suggest that with successful treatment, individuals with BDD demonstrate reduced neurocognitive deficits (detail processing, emotion recognition, maladaptive beliefs) and that CBT is more likely than SPT to improve maladaptive appearance beliefs. More work is needed to understand mechanisms of change and thus maximize treatment outcomes.

Understanding and treating body dysmorphic disorder

Body dysmorphic disorder (BDD) is a mental disorder that involves a distressing preoccupation with a perceived defect in physical appearance, associated with excessive or repetitive behaviours or mental acts aimed at camouflaging, checking or 'improving' the perceived area of concern. BDD is relatively common, affecting at least 2% of the population world-wide, yet is poorly understood. Professor Susan Rossell has produced a substantial body of influential research, which has improved our understanding of BDD. This includes a more comprehensive understanding of the phenomenology, neurocognition and neurobiology, as well as significant treatment advances. This work will be reviewed in this commentary.

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.

Neural and behavioral effects of modification of visual attention in body dysmorphic disorder

In individuals with body dysmorphic disorder (BDD), perceptual appearance distortions may be related to selective attention biases and aberrant visual scanning, contributing to imbalances in global vs. detailed visual processing. Treatments for the core symptom of perceptual distortions are underexplored in BDD; yet understanding their mechanistic effects on brain function is critical for rational treatment development. This study tested a behavioral strategy of visual-attention modification on visual system brain connectivity and eye behaviors. We acquired fMRI data in 37 unmedicated adults with BDD and 30 healthy controls. Participants viewed their faces naturalistically (naturalistic viewing), and holding their gaze on the image center (modulated viewing), monitored with an eye-tracking camera. We analyzed dynamic effective connectivity and visual fixation duration. Modulated viewing resulted in longer mean visual fixation duration compared to during naturalistic viewing, across groups. Further, modulated viewing resulted in stronger connectivity from occipital to parietal dorsal visual stream regions, also evident during the subsequent naturalistic viewing, compared with the initial naturalistic viewing, in BDD. Longer fixation duration was associated with a trend for stronger connectivity during modulated viewing. Those with more severe BDD symptoms had weaker dorsal visual stream connectivity during naturalistic viewing, and those with more negative appearance evaluations had weaker connectivity during modulated viewing. In sum, holding a constant gaze on a non-concerning area of one's face may confer increased communication in the occipital/parietal dorsal visual stream, facilitating global/holistic visual processing. This effect shows persistence during subsequent naturalistic viewing. Results have implications for perceptual retraining treatment designs.

Zoomers: videoconferencing, appearance concerns, and potential effects on adolescents

PURPOSE OF REVIEW

The cessation of in-person teaching to reduce the spread of COVID-19 dramatically increased the use of videoconferencing for home learning among adolescents.

RECENT FINDINGS

A consistent finding across studies assessing the relationship between videoconferencing and appearance concerns was that time spent focused on self-view was related to greater appearance concerns. Videoconferencing was associated with an increase in desire for cosmetic surgery and other nonsurgical treatments. Among those at risk of eating disorders, videoconferencing was associated with more appearance-management behaviours and less engagement in the video call. Research to date has been correlational and predominantly involved White, adult women in the USA and in Australia, leaving important gaps in our knowledge, especially around impacts on adolescents.

SUMMARY

Given their vulnerability to appearance concerns, we encourage practitioners to speak to adolescents about their use of videoconferencing and how they can migitate the potential negative impacts on body image.

Dynamic Effective Connectivity Patterns During Rapid Face Stimuli Presentation in Body Dysmorphic Disorder

In individuals with body dysmorphic disorder (BDD), perceptual appearance distortions may be related to imbalances in global vs. local visual processing. Understanding the mechanistic brain effects of potential interventions is crucial for rational treatment development. The dorsal visual stream (DVS) is tuned to rapid image presentation, facilitating global/holistic processing, whereas the ventral visual stream (VVS), responsible for local/detailed processing, reduces activation magnitude with shorter stimulus duration. This study tested a strategy of rapid, short-duration face presentation on visual system connectivity. Thirty-eight unmedicated adults with BDD and 29 healthy controls viewed photographs of their faces for short (125 ms, 250 ms, 500 ms) and long (3000 ms) durations during fMRI scan. Dynamic effective connectivity in DVS and VVS was analyzed. BDD individuals exhibited weaker connectivity from occipital to parietal DVS areas than controls for all stimuli durations. Short compared with long viewing durations (125 ms vs. 3,000 ms and 500 ms vs. 3,000 ms) resulted in significantly weaker VVS connectivity from calcarine cortex to inferior occipital gyri in controls; however, there was only a trend for similar results in BDD. The DVS to VVS ratio, representing a balance between global and local processing, incrementally increased with shorter viewing durations in BDD, although it was not statistically significant. In sum, visual systems in those with BDD are not as responsive as in controls to rapid face presentation. Whether rapid face presentation could reduce connectivity in visual systems responsible for local/detailed processing in BDD may necessitate different parameters or strategies. These results provide mechanistic insights for perceptual retraining treatment designs.

Brain functional correlates of emotional face processing in body dysmorphic disorder

Previous neuroimaging studies in body dysmorphic disorder (BDD) have focused on discordances in visual processing systems. However, little is known about brain functional aberrations in individuals with BDD during emotional face processing. An fMRI paradigm with negative emotional faces was employed in 20 individuals with BDD and 43 mentally healthy controls (HC). We compared functional activity and whole-brain connectivity patterns of the amygdala and the fusiform gyrus (FFG) between both groups. Regression analyses were performed for associations of body dysmorphic symptoms with brain activity and connectivity. Individuals with BDD exhibited higher activity in the left amygdala compared to HC (p_FWE = .04) as well as increased functional connectivity of the left amygdala with a network including frontostriatal and temporal regions (p_FWE < .05). The FFG revealed increased functional connectivity in individuals with BDD, mapping to brain areas such as the cingulate cortex and temporo-limbic regions (p_FWE < .05). In HC, higher levels of body dysmorphic symptoms were associated with higher functional amygdala and FFG activity (p_FWE < .05). Individuals with BDD show aberrant functional activity and connectivity patterns within the amygdala and the FFG for negative emotional face processing. Body dysmorphic symptoms in HC are associated with a mild pattern of brain functional alterations, which could emphasize the relevance of a dimensional approach in addition to diagnosis. Treatments for BDD could benefit from targeting visual misperception and evaluation processes upon confrontation with emotional information.

Is the needle as risky as the knife? The prevalence and risks of body dysmorphic disorder in women undertaking minor cosmetic procedures

OBJECTIVES

Body dysmorphic disorder is commonly considered a contraindication for major cosmetic surgery, but whether body dysmorphic disorder relates to poorer outcomes from minor cosmetic treatment remains unknown. This study aimed to explore the prevalence of body dysmorphic disorder in clients seeking non-surgical cosmetic procedures and to examine whether body dysmorphic disorder clients are vulnerable in minor cosmetic settings. Vulnerability was explored in terms of psychological distress, unrealistic expectations and motivations for treatment outcome, and reduced satisfaction with past cosmetic procedures.

METHOD

A cross-sectional online survey was completed by 154 women seeking minor cosmetic procedures which included the Body Dysmorphic Disorder Questionnaire - Dermatology Version to screen for body dysmorphic disorder, and measures of cosmetic treatment motivation, expectations and satisfaction.

RESULTS

Roughly 25% of women in the current sample screened positive for a potential body dysmorphic disorder diagnosis. Participants with suspected body dysmorphic disorder demonstrated higher levels of psychological distress and more unrealistic expectations and motivations for cosmetic treatment, such as improving social or romantic relationships. However, body dysmorphic disorder participants reported similar levels of satisfaction with past minor cosmetic treatments to the non-body dysmorphic disorder group.

CONCLUSION

While the relationship between body dysmorphic disorder and treatment outcome warrants further investigation in prospective research tracking satisfaction and adverse reactions over time, this preliminary evidence suggests clients with suspected body dysmorphic disorder display several vulnerabilities in non-surgical cosmetic settings. Given the rapidly increasing accessibility of minor cosmetic procedures, further research is needed to determine their safety for clients with body dysmorphic disorder. Detection of body dysmorphic disorder in non-surgical cosmetic settings could facilitate earlier psychological intervention, promoting superior long-term outcomes.

The Zoom Effect: Exploring the Impact of Video Calling on Appearance Dissatisfaction and Interest in Aesthetic Treatment During the COVID-19 Pandemic

BACKGROUND

The popularity of videoconferencing platforms has skyrocketed during the COVID-19 pandemic; however, concerns have been expressed regarding the potential for video calls to promote appearance dissatisfaction because individuals are exposed to an image of themselves on camera for extended periods.

OBJECTIVES

The aim of the current study was to characterize current video usage behaviors and their relation to appearance dissatisfaction and interest in aesthetic procedures in the general population.

METHODS

An online survey was completed by 335 adults currently living in Australia. Multiple aspects of video usage were assessed, including engagement in video-manipulation techniques to enhance appearance and the focus of visual attention (ie, on self or others) while on video calls. The Dysmorphic Concern Questionnaire was administered to determine if video-use behaviors were associated with greater body image disturbance.

RESULTS

Over one-third of participants had identified new appearance concerns while on video. Dysmorphic concern was associated with self-focused attention, greater engagement in video-manipulation behaviors, and increasing appearance concerns due to their time on video calls. Individuals who identified new video-based appearance concerns reported greater interest in obtaining future beauty treatments (eg, waxing) and aesthetic procedures (eg, nonsurgical procedures such as antiwrinkle injections).

CONCLUSIONS

This is one of first empirical studies to report the potential consequences of video-call usage for increasing appearance dissatisfaction and dysmorphic concern, and to demonstrate a link between the use of video calls and interest in cosmetic procedures.

Effects of visual attention modulation on dynamic functional connectivity during own-face viewing in body dysmorphic disorder

Body dysmorphic disorder (BDD) is characterized by preoccupations with misperceptions of one's physical appearance. Previous neuroimaging studies in BDD have yet to examine dynamic functional connectivity (FC) patterns between brain areas, necessary to capture changes in activity in response to stimuli and task conditions. We used Leading Eigenvector Dynamics Analysis to examine whole-brain dynamic FC from fMRI data during an own-face viewing task in 29 unmedicated adults with BDD with facial concerns and 30 healthy controls. The task involved two parts: (1) unconstrained, naturalistic viewing and (2) holding visual attention in the center of the image, to reduce scanning and fixation on perceived facial flaws. An FC state consisting of bilateral medial orbitofrontal cortex regions occurred significantly less often during the visual attention condition and afterward during the unconstrained face viewing in BDD participants, compared to the first unconstrained face viewing, a pattern that differed from controls. Moreover, the probability of this state during the second unconstrained face viewing was associated with severity of obsessions and compulsions and degree of poor insight in BDD, suggesting its clinical significance. These findings have implications for understanding the pathophysiology of own-face viewing in BDD and how it is affected by modification of viewing patterns, which may have implications for novel perceptual retraining treatment designs.

Brain activation and connectivity in anorexia nervosa and body dysmorphic disorder when viewing bodies: relationships to clinical symptoms and perception of appearance

Anorexia nervosa (AN) and body dysmorphic disorder (BDD) are characterized by distorted perception of appearance, yet no studies have directly compared the neurobiology associated with body perception. We compared AN and BDD in brain activation and connectivity in relevant networks when viewing images of others' bodies and tested their relationships with clinical symptoms and subjective appearance evaluations. We acquired fMRI data from 64 unmedicated females (20 weight-restored AN, 23 BDD, 21 controls) during a matching task using unaltered or spatial-frequency filtered photos of others' bodies. Using general linear model and independent components analyses we compared brain activation and connectivity in visual, striatal, and parietal networks and performed univariate and partial least squares multivariate analyses to investigate relationships with clinical symptoms and appearance evaluations. AN and BDD showed partially overlapping patterns of hyperconnectivity in the dorsal visual network and hypoconnectivity in parietal network compared with controls. BDD, but not AN, demonstrated hypoactivity in dorsal visual and parietal networks compared to controls. Further, there were significant activity and connectivity differences between AN and BDD in both networks. In both groups, activity and/or connectivity were associated with symptom severity and appearance ratings of others' bodies. Thus, AN and BDD demonstrate both distinct and partially-overlapping aberrant neural phenotypes involved in body processing and visually encoding global features. Nevertheless, in each disorder, aberrant activity and connectivity show relationships to clinically relevant symptoms and subjective perception. These results have implications for understanding distinct and shared pathophysiology underlying perceptual distortions of appearance and may inform future novel treatment strategies.

Is poor global processing a transdiagnostic feature of Body Dysmorphic Disorder and Anorexia Nervosa? A meta-analysis

Body dysmorphic disorder (BDD) and anorexia nervosa (AN) are characterised by body image disturbance. It has been suggested that poor global integration in visual processing may underlie distorted body image, but empirical studies have yielded mixed results. The current study involved two meta-analyses aimed at examining the extent to which poor global processing is evident in BDD and AN. Studies were identified through a systematic literature search up to October 2020. The BDD search yielded 16 studies and the AN search yielded 18 studies. Random-effect models demonstrated a small pooled effect size for BDD (g = -0.44, 95 % CI -0.70, -0.17, p < 0.001) and a moderate pooled effect size for AN (g = -0.63, 95 % CI -0.77, -0.49, p <  .001), with no evidence of significant publication bias for either. The results provide evidence that poor global processing is a transdiagnostic feature of both BDD and AN, although effects may be more pronounced in AN. Our findings highlight the possibility that interventions aimed at promoting global visual processing could prove beneficial in disorders characterised by distorted body image.

Empirical evidence for cognitive subgroups in body dysmorphic disorder

OBJECTIVE

Current understanding of cognitive functioning in body dysmorphic disorder is limited, owing to few studies, small sample sizes and assessment across only limited cognitive domains. Existing research has also shown inconsistent findings, with both intact and impaired cognition reported in body dysmorphic disorder, which might point towards cognitive heterogeneity in the disorder. This study aimed to examine the cognitive profile of body dysmorphic disorder in a large sample across eight cognitive domains, and to explore whether cognitive subgroups might be identified within body dysmorphic disorder.

METHOD

Cognitive domains of inhibition/flexibility, working memory, speed of processing, reasoning and problem-solving, visual and verbal learning, attention/vigilance and social cognition were assessed and compared between 65 body dysmorphic disorder patients and 70 healthy controls. Then, hierarchical clustering analysis was conducted on the body dysmorphic disorder group's cognitive data.

RESULTS

Group-average comparisons demonstrated significantly poorer cognitive functioning in body dysmorphic disorder than healthy controls in all domains except for attention/vigilance and social cognition. Cluster analysis identified two divergent cognitive subgroups within our body dysmorphic disorder cohort characterised by (1) broadly intact cognitive function with mild selective impairments (72.3%), and (2) broadly impaired cognitive function (27.7%). However, the clusters did not significantly differ on clinical parameters or most sociodemographic characteristics.

CONCLUSION

Our findings demonstrate considerable cognitive heterogeneity among persons with body dysmorphic disorder, rather than uniform deficits. Poor performances in the broadly impaired subgroup may have driven group-level differences. However, our findings also suggest a dissociation between cognitive functioning and clinical characteristics in body dysmorphic disorder that has implications for current aetiological models. Additional research is needed to clarify why some people with body dysmorphic disorder demonstrate cognitive deficits while others do not.

Body dysmorphic disorder: a treatment synthesis and consensus on behalf of the International College of Obsessive-Compulsive Spectrum Disorders and the Obsessive Compulsive and Related Disorders Network of the European College of Neuropsychopharmacology

Body dysmorphic disorder (BDD) is characterized by a preoccupation with a perceived appearance flaw or flaws that are not observable to others. BDD is associated with distress and impairment of functioning. Psychiatric comorbidities, including depression, social anxiety, and obsessive-compulsive disorder are common and impact treatment. Treatment should encompass psychoeducation, particularly addressing the dangers associated with cosmetic procedures, and may require high doses of selective serotonin reuptake inhibitors* (SSRI*) and protracted periods to establish full benefit. If there is an inadequate response to SSRIs, various adjunctive medications can be employed including atypical antipsychotics*, anxiolytics*, and the anticonvulsant levetiracetam*. However, large-scale randomized controlled trials are lacking and BDD is not an approved indication for these medications. Oxytocin* may have a potential role in treating BDD, but this requires further exploration. Cognitive-behavioural therapy has good evidence for efficacy for BDD, and on-line and telephone-assisted forms of therapy are showing promise. CBT for BDD should be customized to address such issues as mirror use, perturbations of gaze, and misinterpretation of others' emotions, as well as overvalued ideas about how others view the individual.

Two Case Studies of Delusions Leading to Suicide, a Selective Review

Many questions pertaining to delusional disorder (DD) remain unanswered. It is unclear what syndromes to include under this category of psychotic illness and when to treat with antidepressants, cognitive therapy, or antipsychotic medication. DD is associated with psychiatric comorbidity, especially depression, and rates of suicidal behavior are high when the two conditions co-exist. In this selective review, we present two instances of suicide in the context of DD, one illustrating risks for the somatic subtype and the second, risks for the persecutory subtype. The frequency of suicidal behaviour in these two subtypes of DD is estimated at 8-21%. The literature suggests a prominent role for social emotions (shame, humiliation) in the pathway leading to suicide. In addition, risk factors found in our two patients point to factors such as poverty, living alone, vulnerable risk periods, stigma, and lack of trust in mental health services. Building trust may be the most effective preventive measure.

Examining memory performance in body dysmorphic disorder (BDD): A comparison study with obsessive compulsive disorder (OCD)

The aim of this study is comparing directly the BDD and OCD disorders in terms of similarities and differences in memory function for the first time. 19 BDD patients, 15 OCD patients and 26 individuals in a healthy control group were recruited from three hospitals in Tehran. They were administered the following subtests of the Wechsler Memory Scale: logical memory (immediate and delayed), verbal paired association (immediate and delayed), digit span and spatial span as well as the Rey-Osterrieth complex figure test (RCFT). The results showed that BDD and OCD groups had lower performance in comparison to the control group across all measures, except for the immediate memory of the verbal paired associate task, which was similar across the three groups. Both the BDD and OCD groups showed poor performance on the auditory-verbal memory tasks. However, only the BDD group showed poor performance in the visual domain (i.e. spatial span and RCFT). This suggest that memory deficits are similar between BDD and OCD patients in the verbal domain. Furthermore, BDD patients demonstrated poorer visual working memory. The findings of this study reveal that BDD and OCD patients have more similarities than differences regarding neuropsychological features, in other words, the idea of the incorporation of BDD within the obsessive-compulsive and related disorders (OCRDs) spectrum in DSM-5 is supported, at least through the viewpoint of neuropsychology.

Comparison of body image evaluation by virtual reality and paper-based figure rating scales in adolescents with anorexia nervosa: retrospective study

PURPOSE

Assessment of the symptoms of body image disorder (BID) is crucial in anorexia nervosa (AN). Recent technological advancements such as virtual reality (VR) have improved the visual perception with 3D avatars and the feeling to be the avatar with the immersive conditions. This retrospective study examines the hypothesis that VR with standardized 3D avatars would improve body image perception and then body image evaluation by adolescents with AN, compared to the paper-based figure rating scales (FRS).

METHODS

Data of 31 female adolescents with AN were retrospectively studied. Paired data of perceived and desired body forms in addition to body perception index (BPI) (p = 0.2) and body dissatisfaction (p = 0.6), obtained by both VR and FRS were compared. Furthermore, correlation with validated psychometric questionnaires was also studied. Head-tracking technology allowed for the implicit measurement of explicit choices of patients.

RESULTS

Participants with AN overestimated own body size regardless of the assessment tool used. BPI and body dissatisfaction did not differ significantly between FRS and VR. VR-based evaluation was correlated with the psychometric parameters BID and body dissatisfaction. Head tracking revealed significantly longer participant engagement with avatars representing malnutrition and underweight states, while those least engaged corresponded to obesity.

CONCLUSIONS

Results of BID evaluation by VR standardized 3D avatars are comparable to those obtained by paper-based FRS. These findings suggest that comparable results obtained by both tools of evaluation reflect primarily the role of affective-cognitive perturbation in BID. The perceptive component could be better evaluated using biometric-enhanced assessment tools.

LEVEL OF EVIDENCE

Level V, cross-sectional descriptive study (evaluation data retrospectively studied).

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

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.

Intranasal oxytocin alters amygdala-temporal resting-state functional connectivity in body dysmorphic disorder: A double-blind placebo-controlled randomized trial

The aetiology of body dysmorphic disorder (BDD) is poorly understood. Recent evidence from functional brain imaging studies suggests that BDD is associated with aberrant task-based functional connectivity and that intranasal oxytocin (OXT) may improve network connectivity in BDD patients. Thus, the aim of this study was to investigate the effect of intranasal OXT on amygdala resting-state functional connectivity (rsFC) in BDD. In a randomized, double-blind, cross-over design, 19 BDD participants and 17 demographically matched healthy control participants received intranasal OXT (24 IU) or placebo prior to resting-state functional magnetic resonance imaging. The left and right amygdala were seeded as regions of interest, and temporal correlations between the amygdalae and all other voxels comprising cortical and subcortical grey matter were investigated. Compared to healthy controls, BDD patients showed greater baseline (placebo) rsFC between the left amygdala and two clusters within the left temporal lobe and one cluster within the superior frontal gyrus which was reversed following OXT administration. The control group also showed significantly greater rsFC between the left amygdala and anterior prefrontal cortex in the OXT session compared to placebo. Whilst preliminary, these findings suggest that BDD patients exhibit abnormal amygdala-temporal connectivity at rest, and OXT might have a role in changing this functional relationship.

Differentiating weight-restored anorexia nervosa and body dysmorphic disorder using neuroimaging and psychometric markers

Anorexia nervosa (AN) and body dysmorphic disorder (BDD) are potentially life-threatening conditions whose partially overlapping phenomenology—distorted perception of appearance, obsessions/compulsions, and limited insight—can make diagnostic distinction difficult in some cases. Accurate diagnosis is crucial, as the effective treatments for AN and BDD differ. To improve diagnostic accuracy and clarify the contributions of each of the multiple underlying factors, we developed a two-stage machine learning model that uses multimodal, neurobiology-based, and symptom-based quantitative data as features: task-based functional magnetic resonance imaging data using body visual stimuli, graph theory metrics of white matter connectivity from diffusor tensor imaging, and anxiety, depression, and insight psychometric scores. In a sample of unmedicated adults with BDD (n = 29), unmedicated adults with weight-restored AN (n = 24), and healthy controls (n = 31), the resulting model labeled individuals with an accuracy of 76%, significantly better than the chance accuracy of 35% (p^<10‑4). In the multivariate model, reduced white matter global efficiency and better insight were associated more with AN than with BDD. These results improve our understanding of the relative contributions of the neurobiological characteristics and symptoms of these disorders. Moreover, this approach has the potential to aid clinicians in diagnosis, thereby leading to more tailored therapy.

Preliminary Evidence of a Missing Self Bias in Face Perception for Individuals with Dissociative Identity Disorder

Failing to recognize one's mirror image can signal an abnormality in one's sense of self. In dissociative identity disorder (DID), individuals often report that their mirror image can feel unfamiliar or distorted. They also experience some of their own thoughts, emotions, and bodily sensations as if they are nonautobiographical and sometimes as if instead, they belong to someone else. To assess these experiences, we designed a novel backwards masking paradigm in which participants were covertly shown their own face, masked by a stranger's face. Participants rated feelings of familiarity associated with the strangers' faces. 21 control participants without trauma-generated dissociation rated masks, which were covertly preceded by their own face, as more familiar compared to masks preceded by a stranger's face. In contrast, across two samples, 28 individuals with DID and similar clinical presentations (DSM-IV Dissociative Disorder Not Otherwise Specified type 1) did not show increased familiarity ratings to their own masked face. However, their familiarity ratings interacted with self-reported identity state integration. Individuals with higher levels of identity state integration had response patterns similar to control participants. These data provide empirical evidence of aberrant self-referential processing in DID/DDNOS and suggest this is restored with identity state integration.

Visual training program for body dysmorphic disorder: protocol for a novel intervention pilot and feasibility trial

Background

Body dysmorphic disorder (BDD) is a characterised by perceived defects or flaws in appearance which are associated with distressing thoughts, repetitive or obsessive behaviours, and significant impairment in social and occupational functioning. A core feature of BDD involves abnormalities of visual processing, although this is not typically a focus of psychological and psychiatric treatments. While current treatments generally show moderate effectiveness in the short-term, those with BDD can have high relapse rates, as they still 'see' their flaws or defects. The current research trials a visual training program designed to remediate visual abnormalities and reduce symptom severity of BDD.

Methods

This is a single-group open-label pilot study assessing the feasibility and potential efficacy of a 10-week visual training program. This pilot trial will be conducted at Swinburne University of Technology, Melbourne, Australia, and will recruit up to 20 participants diagnosed with BDD. These participants will complete pre- and post-assessments and a 10-week visual training program encompassing three phases of basic visual processing, face and emotion recognition, and self-perception. The primary outcomes focus on feasibility and acceptability of the intervention, with secondary outcomes exploring clinical outcomes related to symptom severity, quality of life and eye movements.

Discussion

This pilot trial will translate the empirical findings of abnormalities in visual processing among those diagnosed with BDD, to an innovative treatment method across a range of visual processing levels. This trial will assess the feasibility and potential efficacy of such a visual training program, paving the way for further research including a future definitive randomised control trial.

Trial registration

Australian New Zealand Clinical Trial Registry, ACTRN 12618000274279, Registered 22nd February 2018.

Sex differences in own and other body perception

Own body perception, and differentiating and comparing one's body to another person's body, are common cognitive functions that have relevance for self‐identity and social interactions. In several psychiatric conditions, including anorexia nervosa, body dysmorphic disorder, gender dysphoria, and autism spectrum disorder, self and own body perception, as well as aspects of social communication are disturbed. Despite most of these conditions having skewed prevalence sex ratios, little is known about whether the neural basis of own body perception differs between the sexes. We addressed this question by investigating brain activation using functional magnetic resonance imaging during a Body Perception task in 15 male and 15 female healthy participants. Participants viewed their own body, bodies of same‐sex, or opposite‐sex other people, and rated the degree that they appeared like themselves. We found that men and women did not differ in the pattern of brain activation during own body perception compared to a scrambled control image. However, when viewing images of other bodies of same‐sex or opposite‐sex, men showed significantly stronger activations in attention‐related and reward‐related brain regions, whereas women engaged stronger activations in striatal, medial‐prefrontal, and insular cortices, when viewing the own body compared to other images of the opposite sex. It is possible that other body images, particularly of the opposite sex, may be of greater salience for men, whereas images of own bodies may be more salient for women. These observations provide tentative neurobiological correlates to why women may be more vulnerable than men to conditions involving own body perception.

The relationship between body dysmorphic disorder and obsessive-compulsive disorder: A systematic review of direct comparative studies

OBJECTIVE

Current nosology conceptualises body dysmorphic disorder as being related to obsessive-compulsive disorder, but the direct evidence to support this conceptualisation is mixed. In this systematic review, we aimed to provide an integrated overview of research that has directly compared body dysmorphic disorder and obsessive-compulsive disorder.

METHOD

The PubMed database was searched for empirical studies which had directly compared body dysmorphic disorder and obsessive-compulsive disorder groups across any subject matter. Of 379 records, 31 met inclusion criteria and were reviewed.

RESULTS

Evidence of similarities between body dysmorphic disorder and obsessive-compulsive disorder was identified for broad illness features, including age of onset, illness course, symptom severity and level of functional impairment, as well as high perfectionism and high fear of negative evaluation. However, insight was clearly worse in body dysmorphic disorder than obsessive-compulsive disorder, and preliminary data also suggested unique visual processing features, impaired facial affect recognition, increased social anxiety severity and overall greater social-affective dysregulation in body dysmorphic disorder relative to obsessive-compulsive disorder.

CONCLUSION

Limitations included a restricted number of studies overall, an absence of studies comparing biological parameters (e.g. neuroimaging), and the frequent inclusion of participants with comorbid body dysmorphic disorder and obsessive-compulsive disorder. Risks of interpreting common features as indications of shared underlying mechanisms are explored, and evidence of differences between the disorders are placed in the context of broader research findings. Overall, this review suggests that the current nosological status of body dysmorphic disorder is somewhat tenuous and requires further investigation, with particular focus on dimensional, biological and aetiological elements.

Evolutionary perspective on sex differences in the expression of neurological diseases

Sex-specific brain and cognitive deficits emerge with malnutrition, some infectious and neurodegenerative diseases, and often with prenatal or postnatal toxin exposure. These deficits are described in disparate literatures and are generally not linked to one another. Sexual selection may provide a unifying framework that integrates our understanding of these deficits and provides direction for future studies of sex-specific vulnerabilities. Sexually selected traits are those that have evolved to facilitate competition for reproductive resources or that influence mate choices, and are often larger and more complex than other traits. Critically, malnutrition, disease, chronic social stress, and exposure to man-made toxins compromise the development and expression of sexually selected traits more strongly than that of other traits. The fundamental mechanism underlying vulnerability might be the efficiency of mitochondrial energy capture and control of oxidative stress that in turn links these traits to current advances in neuroenergetics, stress endocrinology, and toxicology. The key idea is that the elaboration of these cognitive abilities, with more underlying gray matter or more extensive inter-modular white matter connections, makes them particularly sensitive to disruptions in mitochondrial functioning and oxidative stress. A framework of human sexually selected cognitive abilities and underlying brain systems is proposed and used to organize what is currently known about sex-specific vulnerabilities.

Set shifting and visuospatial organization deficits in body dysmorphic disorder

Individuals with body dysmorphic disorder (BDD) over-attend to perceived defect(s) in their physical appearance, often becoming "stuck" obsessing about perceived flaws and engaging in rituals to hide flaws. These symptoms suggest that individuals with BDD may experience deficits in underlying neurocognitive functions, such as set-shifting and visuospatial organization. These deficits have been implicated as risk and maintenance factors in disorders with similarities to BDD but have been minimally investigated in BDD. The present study examined differences in neurocognitive functions among BDD participants (n = 20) compared to healthy controls (HCs; n = 20). Participants completed neuropsychological assessments measuring set-shifting (Cambridge Neuropsychological Test Automated Battery Intra-Extra Dimensional Set Shift [IED] task) and visuospatial organization and memory (Rey-Osterrieth Complex Figure Test [ROCF]). Results revealed a set-shifting deficit among BDD participants compared to HCs on the IED. On the ROCF, BDD participants exhibited deficits in visuospatial organization compared to HCs, but they did not differ in visuospatial memory compared to HCs. Results did not change when accounting for depression severity. Findings highlight neurocognitive deficits as potential endophenotype markers of clinical features (i.e., delusionality). Understanding neuropsychological deficits may clarify similarities and differences between BDD and related disorders and may guide targets for BDD treatment.

The classification of body dysmorphic disorder symptoms in male and female adolescents

BACKGROUND

Body dysmorphic disorder (BDD) was categorised in DSM-5 within the newly created 'obsessive-compulsive and related disorders' chapter, however this classification remains subject to debate. Confirmatory factor analysis was used to test competing models of the co-occurrence of symptoms of BDD, obsessive-compulsive disorder, unipolar depression, anxiety, and eating disorders in a community sample of adolescents, and to explore potential sex differences in these models.

METHODS

Self-report questionnaires assessing disorder symptoms were completed by 3149 Australian adolescents. The fit of correlated factor models was calculated separately in males and females, and measurement invariance testing compared parameters of the best-fitting model between males and females.

RESULTS

All theoretical models of the classification of BDD had poor fit to the data. Good fit was found for a novel model where BDD symptoms formed a distinct latent factor, correlated with affective disorder and eating disorder latent factors. Metric non-invariance was found between males and females, and the majority of factor loadings differed between males and females. Correlations between some latent factors also differed by sex.

LIMITATIONS

Only cross-sectional data were collected, and the study did not assess a broad range of DSM-5 defined eating disorder symptoms or other disorders in the DSM-5 obsessive-compulsive and related disorders chapter.

CONCLUSIONS

This study is the first to statistically evaluate competing models of BDD classification. The findings highlight the unique features of BDD and its associations with affective and eating disorders. Future studies examining the classification of BDD should consider developmental and sex differences in their models.

How individuals with body dysmorphic disorder (BDD) process their own face: a quantitative and qualitative investigation based on an eye-tracking paradigm

INTRODUCTION

Body dysmorphic disorder (BDD) is characterised by repetitive behaviours and/or mental acts occurring in response to preoccupations with perceived flaws in physical appearance. Based on an eye-tracking paradigm, this study aimed to examine how individuals with BDD processed their own face.

METHODS

Participants were 21 BDD patients, 19 obsessive-compulsive disorder patients and 21 healthy controls (HC), who were age-, sex-, and IQ-matched. Stimuli were photographs of participants' own faces as well as those from the Pictures of Facial Affect battery. Outcome measures were affect recognition accuracy as well as spatial and temporal scanpath parameters.

RESULTS

The BDD group exhibited significantly decreased recognition accuracy for their own face relative to the HC group, and this was most pronounced for those who had a key concern centred on their face. Individual qualitative scanpath analysis revealed restricted and extensive scanning behaviours in BDD participants with a facial preoccupation. Persons with severe BDD also exhibited more marked scanpath deficits.

CONCLUSIONS

Future research should be directed at extending the current work by incorporating neuroimaging techniques, and investigations of eye-tracking focused on affected body parts in BDD. These could yield fruitful therapeutic applications via incorporation with existing treatment approaches.

Treatment Modifications and Suggestions to Address Visual Abnormalities in Body Dysmorphic Disorder

Recent psychophysical and neurocognitive findings implicate abnormal visual processing for a range of stimuli in body dysmorphic disorder (BDD); such abnormalities differentiate BDD from other mental health disorders. Current treatments most commonly involve cognitive behavior therapy with or without accompanying antidepressant medications. These are moderately successful yet appear to overlook the core phenomenological aspect of abnormal perception in BDD. The following text summarizes the current literature of perceptual abnormalities within BDD and how these findings may be applied and incorporated into treatment options. Possible modifications of cognitive behavioral therapy (CBT) based on the widespread visual abnormalities within BDD include making perceptual mirror retraining a compulsory component of therapy and implementing self-exposure tasks within exposure and response prevention. Alternative options such as a visual training program to remediate visual abnormalities across a range of visual stimuli are also explored, which may be included as an adjunctive treatment alongside CBT.