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.

Relationships between paranoia and body image concern among community women.

Previous research has indicated that lifetime body image concerns are associated with increased odds of paranoid ideation. In this study, we sought to replicate and extend this finding by exploring how paranoia relates to different aspects of body image concern using a comprehensive, cross-sectional design. Women without a mental health diagnosis (n = 119) completed online questionnaires assessing paranoia, shape and weight concerns, and figure ratings for how they "think" their body looks and how they "feel" in their body. Participant's "actual" figure ratings were estimated from height and weight; discrepancy scores were then calculated for "actual-think" and "actual-feel" figure ratings. Correlational analyses, and mediation models testing paranoia as a mediator between "actual-feel" and shape and weight concerns, were conducted. Paranoia was significantly correlated with increased shape and weight concerns, and with "feeling" larger. Paranoia significantly mediated paths from feeling larger to increased shape or weight concerns. There were no significant associations of paranoia with "actual-think" ratings. Limitations include that height and weight data could not be objectively confirmed, and only women were included in the study. Further research is needed to understand mechanisms by which paranoia may influence shape and weight concerns and vice versa, and how "feeling" larger may feed paranoia. Future research should investigate these relationships among clinical eating disorder groups.

The contribution of sleep to anorexia nervosa severity.

PURPOSE: Anorexia nervosa (AN) is associated with poor sleep and altered circadian rhythms. Evidence is unclear as to whether these features relate to ongoing psychiatric symptoms of AN, or are merely concomitant with low weight. In this study, we sought to evaluate subjective sleep quality and sleep-wake preferences in a sample of individuals with lifetime AN. Furthermore, we aimed to examine whether sleep quality would significantly predict AN symptom severity, after accounting for demographic features and negative emotions (depression, anxiety and stress). METHODS: Adults with a lifetime diagnosis of AN (n = 96) or no lifetime psychiatric diagnoses (NC; n = 246) completed an online survey assessing demographics, sleep quality, circadian sleep-wake preferences, eating disorder symptoms, and negative emotions. RESULTS: AN participants reported significantly poorer sleep quality overall, including increased sleep disturbances, use of sleep medications, and daytime dysfunction, as compared to NC participants. Groups did not differ significantly in circadian sleep-wake preferences. Regression analysis showed that among AN participants, sleep quality and negative emotions significantly predicted AN symptom severity, while sex and body mass index (BMI) did not. CONCLUSION: The findings demonstrate that poor sleep quality was associated with more severe symptoms of AN, even when accounting for negative emotions and BMI. Future research should investigate causal interactions between sleep quality and AN symptom severity longitudinally and across different recovery stages. LEVEL OF EVIDENCE: Level III-Cohort and case-control analytic studies.

Valuing the voice of lived experience of eating disorders in the research process: Benefits and considerations.

Although the inclusion of individuals with lived experience is encouraged within the research process, there remains inconsistent direct involvement in many mental health fields. Within the eating disorders field specifically, there is a very strong and increasing presence of lived experience advocacy. However, due to a number of potential challenges, research undertaken in consultation or in collaboration with individuals with lived experience of an eating disorder is scarce. This paper describes the significant benefits of the inclusion of individuals with lived experience in research. The specific challenges and barriers faced in eating disorders research are also outlined. It is concluded that in addition to existing guidelines on working with lived experience collaborators in mental health research, more specific procedures are required when working with those with eating disorders.

Cross-diagnostic cognitive heterogeneity in body dysmorphic disorder and obsessive-compulsive disorder.

BACKGROUND AND OBJECTIVES: Previous research has indicated that body dysmorphic disorder (BDD) and obsessive-compulsive disorder (OCD) often demonstrate similar cognitive impairments across multiple domains. However, findings for both disorders have not consistently shown impaired cognition. As such, BDD and OCD might share an overlapping pattern of cognitive heterogeneity, characterised by subgroups with different cognitive profiles. METHODS: To evaluate this possibility, we compared 26 BDD, 24 OCD, and 26 healthy control participants on a comprehensive eight-domain cognitive battery. Then, cluster analysis was performed on the BDD and OCD participants' combined data to explore for cognitive subgroups. RESULTS: No significant differences were found between the three groups' cognitive functioning, except for poorer visual learning in OCD relative to healthy controls. Cluster analysis produced two cognitive subgroups within the combined BDD and OCD data, characterised by intact cognition (52%) and broadly impaired cognition (48%). Each subgroup comprised both BDD and OCD participants, in similar proportions. The subgroups did not differ in clinical or demographic features. LIMITATIONS: Sample sizes were moderate. Future research should investigate clustering patterns both in larger groups and separately in BDD and OCD samples to determine replicability. CONCLUSIONS: These findings suggest that BDD and OCD may involve similar patterns of cognitive heterogeneity, and further imply that individuals with either disorder can show a wide range of cognitive profiles, thus necessitating a nuanced approach to future cognitive research in BDD and OCD.

Childhood maltreatment and trauma is common and severe in body dysmorphic disorder.

BACKGROUND: Childhood maltreatment and trauma may be risk factors for the development of body dysmorphic disorder (BDD). However, the limited research to date on these topics has been constrained by either the absence of a matched healthy control group or non-comprehensive assessments. METHODS: This study assessed the prevalence and severity of childhood maltreatment and other traumatic events in 52 BDD participants (56% female) and 57 matched controls (51% female) with no history of mental illness, using the Childhood Trauma Questionnaire and a checklist assessing broader traumatic events. RESULTS: In comparison with controls, participants with BDD showed a higher prevalence of emotional abuse (61.5% vs. 33.3%) and physical neglect (59.6% vs. 28.1%), as well as more severe overall maltreatment, emotional abuse, and emotional and physical neglect. BDD participants were also more likely to meet cut-offs for multiple types of maltreatment and reported an elevated number and variety of broader traumatic childhood events (e.g., life-threatening illness). In BDD, increasingly severe maltreatment was correlated with greater severity of BDD symptoms, anxiety and suicidal ideation. CONCLUSIONS: These data suggest that childhood maltreatment and exposure to other traumatic events are common and severe in BDD and are cross-sectionally associated with the severity of clinical symptoms. Adversity linked to maladaptive family functioning during childhood may therefore be especially relevant to people with BDD and could relate to social and emotional processing problems in the disorder.

Current directions in biomarkers and endophenotypes for anorexia nervosa: A scoping review.

There are currently no validated biomarkers for anorexia nervosa (AN), though recent literature suggests an increased research interest in this area. Biomarkers are objective, measurable indicators of illness that can be used to assist with diagnosis, risk assessment, and tracking of illness state. Related to biomarkers are endophenotypes, which are quantifiable phenomena that are distinct from symptoms and which link genes to manifest illness. In this scoping review, we sought to provide a summary of recent research conducted in the pursuit of biomarkers and endophenotypes for AN. The findings indicate that a number of possible biomarkers which can assess the presence or severity of AN independently of weight status, including psychophysical (e.g., eye-tracking) and biological (e.g., immune, endocrine, metabolomic, neurobiological) markers, are currently under investigation. However, this research is still in early phases and lacking in replication studies. Endophenotype research has largely been confined to the study of several neurocognitive features, with mixed evidence to support their classification as possible endophenotypes for the disorder. The study of biomarkers and endophenotypes in AN involves significant challenges due to confounding factors of illness-related sequalae, such as starvation. Future research in these areas must prioritise direct evaluation of the sensitivity, specificity and test-retest reliability of proposed biomarkers and enhanced control of confounding physical consequences of AN in the study of biomarkers and endophenotypes.

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.

An update on gender differences in major symptom phenomenology among adults with body dysmorphic disorder.

There has not been a comprehensive comparison of differences between men and women with body dysmorphic disorder (BDD) for approximately two decades. Major social and technological changes over this time may have changed patterns of bodily concerns and symptom profile among men and women with BDD, thus warranting an updated assessment of gender differences. BDD symptomatology, insight, and associated clinical and sociodemographic characteristics were compared between 49 women and 27 men with BDD. Skin was the most common concern for both men and women. Women showed more concerns than men about the appearance of their legs. Men were more concerned about muscularity/body build. Women demonstrated significantly more severe distress associated with BDD behaviours, and poorer illness insight than men. Age at BDD onset, illness duration, as well as mean severity of depression, anxiety, stress, and social anxiety were similar across the genders. These data suggest that the most common body areas of concern in people with BDD have not dramatically changed over the past two decades. However, the finding of worse insight among women is novel, and suggests a need for further investigation.

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.