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Set shifting and visuospatial organization deficits in body dysmorphic disorder
Abstract
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.
... Conversely, cognitive models have reflected the potential role of certain cognitive impairments in BDD development and maintenance (Greenberg et al., 2018;Jefferies-Sewell et al., 2017). In functional neuroimaging studies, OCD symptoms are suggestive of increased activity in orbitofrontal cortex, caudate nucleus, thalamus, and anterior cingulate gyrus (Saxena, Brody, Schwartz, & Baxter, 1998). ...
... Our findings are similar to those reported by Greenberg et al. (2018). ...
... Our study demonstrated a significant difference between both groups during the implementation of section B of TMT; thus implying that individuals with BDD had a weaker visuospatial search than those with no disorders. This is supported by several studies (Deckersbach et al., 2000;Greenberg et al., 2018;Kerwin et al., 2014;Soyata et al., 2018). ...
Background
Body dysmorphic disorder (BDD) is characterized by a preoccupation with an imagined defect in one's appearance. In case of a slight physical anomaly, the person would experience an excessive concern. This disorder causes cognitive dysfunction.
Purpose
The aim of this study was to examine epidemiology of body dysmorphic disorder among students at secondary schools of the first and second stage in Shiraz, Iran. It also compares executive functions in students with BDD to healthy students.
Methods
The Body Dysmorphic Disorder Questionnaire (BDDQ), Stroop Color and Word Test (SCWT),Wisconsin Card Sorting Test (WCST), Tower of London test (ToL), and Trail Making Test (TMT) were measured in participants with BDD (N = 52; Mage = 16.20; SD = 1.03) and healthy control group (N = 52; Mage = 15.91; SD = 0.96).
Results
The frequency of BDD was significantly higher in women than men (14.8% vs. 6.8%), and its prevalence was 10.4% in total. There was a significant difference between the two groups of students concerning attentional set‐shifting, inhibition of cognitive interference, visual‐spatial searching, and sequencing, but not problem‐solving tasks.
Conclusions
Students with BDD have cognitive deficits, which need to be addressed in cognitive rehabilitation.
... Two common tests to assess cold visuospatial functions include the Wechsler Block Design test, and the Rey Complex Figure Test (RCFT) copy trial. Studies assessing visuospatial performance using the RCFT copy trial reported no significant differences between BDD and control samples (Deckersbach et al., 2000;Greenberg et al., 2018;Hanes, 1998). Similarly, Laniti (2005) reported no difference between a BDD and a control sample on the Block Design Test. ...
... Few studies examining nonverbal memory have been conducted among individuals with BDD. Most studies did not find any performance difference between BDD and control samples (Dunai et al., 2010;Greenberg et al., 2018;Hanes, 1998). This is somewhat surprising given that OCD is associated with underperformance on the RCFT, usually exhibiting the largest effect size found across neuropsychological tasks in OCD (Abramovitch, & Cooperman, 2015). ...
... They did not find significant difference between two groups on working memory. Studies found intact performance in individuals with BDD on cognitive functions such as non-verbal memory (Dunai et al., 2010;Greenberg et al., 2018;Hanes, 1998), and visuospatial function (Deckersbach et al., 2000;Laniti, 2005). There are inconsistent findings in studies measured verbal memory, and verbal function in BDD patients. ...
Preoccupation with perceived flaws in physical appearance and body dysmorphic concerns are central symptoms of Body Dysmorphic Disorder (BDD), a condition associated with substantial psychopathological burden, increased suicide risk, and functional disability. Initial research reveals that BDD is associated with deficient cognitive functions. Less is known about Subclinical Body Dysmorphic Disorder (SC-BDD) -a psychometrically defined clinical status that is more prevalent than BDD – particularly in terms of neuropsychological function. Moreover, to date no analogue BDD study using a comprehensive neuropsychological battery has been conducted in college students, a population associated with higher risk for BDD and body image concerns compared to the general population. To fill this gap in the literature, the present study aimed at assessing cognitive functions in a SC-BDD sample using a validated computerized neuropsychological battery among college students. Initially, a sample of 1394 students completed the Dysmorphic Concern Questionnaire (DCQ). Using a psychometrically valid methodology, a SC-BDD (n = 40) and control (n = 39) groups were selected based on scores in the upper and lower quartiles on the DCQ. The two groups completed a comprehensive computerized neuropsychological battery and clinical questionnaires. The SC-BDD sample presented with significantly elevated symptoms of anxiety, stress, and depression. However, no significant differences were found on any neuropsychological outcome measures or domain indexes. Effect sizes were small, some of which favored the SC-BDD group. Despite substantial anxiety and depression symptoms, entailing meaningful psychopathological burden, SC-BDD exhibited intact cognitive functioning. Given the prevalence, severity, and suicide risk associated with SC-BDD, these results are important because intact cognitive functioning may result in misidentification of students who require treatment. Given that years untreated is a negative prognostic indicator, it is important for academic institution to disseminate information to their students regarding body image concerns, and offer specific support in University counselling centers.
... 20 Worse performance on the intra-extradimensional set shifting (IED) in patients with OCD has been reported by Nedeljkovic et al, Watkins et al, Purcell et al, and Chamberlain et al, 16,21-23 but not replicated by Purcell et al, Nielen et al, and Veale et al. 17,24,25 Both Jefferies-Sewell et al and Greenberg et al showed that patients with BDD performed poorer on IED compared with healthy controls. 26,27 SST has been found to be deficient in patients with OCD in several studies, 11,18,23,[28][29][30][31] but recent findings by Kalanthroff et al could not demonstrate any difference, independent of medication status. 32 Similarly, Jefferies-Sewell et al showed worse test performance on the SST among patients with BDD in comparison to healthy controls. ...
... Instead, comparing crude numbers on performance on IED and SST shows that patients with OCD and BDD in our study are comparable to those in previous studies; however, healthy controls perform much better in previous studies. 26,27 Recruiting healthy controls from universities constitutes a risk for selection bias, since university students may have prominent EFs and are therefore not representative for the general population. In addition, OCD is a prevalent comorbidity in patients with BDD from previous studies, up to 75% of all participants in one study. ...
Objective
To assess executive functions (EFs) in patients with body dysmorphic disorder (BDD) and obsessive–compulsive disorder (OCD) compared with healthy controls.
Methods
Adults diagnosed with BDD (n = 26) or OCD (n = 29) according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, and healthy controls (n = 28) underwent validated and computerized neuropsychological tests, spatial working memory (SWM), intra–extra-dimensional set shifting (IED), and stop signal task (SST), from the Cambridge Neuropsychological Test Automated Battery (CANTAB). Test performance was compared between groups, and correlated with standardized symptom severity of BDD and OCD. Significance level was set to P < .05.
Results
There were no statistically significant between-group differences on key outcome measures in SWM, IED, or SST. There was a weak positive correlation between symptom severity and test errors on SWM and IED in both OCD and BDD groups; increased clinical severity was associated with more errors in these tests. Furthermore, there was a negative correlation between symptom severity and SST in the BDD group.
Conclusions
Patients with BDD or OCD did not differ from healthy control subjects in terms of test performance; however, there were several statistically significant correlations between symptom severity and performance in those with BDD or OCD. More studies on EFs in BDD and OCD are required to elucidate if there are differences in EFs between these two disorders.
... A fe la dat vál tást és a vi zu á lis-té ri szer ve zô dést mé rô fe la da tok ban szig ni fi káns mér ték ben gyen géb ben tel je sí tet tek a BDD-s be te gek (n=20) a kont roll cso port hoz (n=20) ké pest, a vizu á lis-té ri me mó ri á ban azon ban nem volt kimu tat ha tó kü lönb ség (116). ...
Body dysmorphic disorder is a common psychiatric disease; its respective prevalence is 2% in the general population, 3.3% in tertiary students, 7.4% among adolescent and adult psychiatric in-patients, and above 10% in patients of cosmetic surgery or dermatology. The most important symptom of the disease is the distorted perception of bodily appearance that leads to low self-esteem, anxiety, depression, social isolation and compulsive behaviours. The disease usually begins during adolescence (average age at onset: 16.7 years), the symptoms have a rather deleterious impact on social relationships, education, work and family life. Comorbidity with affective disorders, anxiety disorders, personality disorders, eating disorders, alcoholism, and substance use disorders is common. The life quality of the affected patients is bad, the risk of suicide is high, and the occurrence of heteroaggressive behaviour is not infrequent either. Despite the great prevalence and the serious consequences, body dysmorphic disorder is diagnosed only in 15% of the cases, and it occurs relatively rarely that the individuals affected by the disease get an adequate treatment. The patients do not usually ask for help because they feel ashamed, or they look for help in wrong places because of lack of insight. In addition, quite many experts working in the health service are not sufficiently familiar with the pheno - mena of this disorder. The authors' objective is to provide a thorough review about body dysmorphic disorder with special regard to the results of the past decade. A substantial recent change is the fact that the disorder, previously categorized in the group of somatoform disorders, has been placed in the group of obsessive-compulsive and related disorders in DSM-5. A complex interplay of biological, psychological and sociocultural factors underlies the etio - patho genesis. Pharmacotherapy with serotonin reuptake inhibitors and cognitive-behavioural therapy are still regarded as the most effective treatments for body dysmorphic disorder. The modifications of the latter developed to target misperception of appearance, emotional dysfunction or perfectionism seem to represent promising therapeutic measures in addition to the application of novel methods of information technology.
... While several studies have indeed demonstrated deficits in global processing among individuals with BDD relative to healthy controls on behavioural tasks (Jefferies, Laws, & Fineberg, 2012;Stangier, Adam-Schwebe, Müller, & Wolter, 2008;Toh, Castle, & Rossell, 2017), others have failed to find such effects (Buhlmann & Wilhelm, 2004;Li, Lai, Bohon et al., 2015;Monzani, Krebs, Anson, Veale, & Mataix-Cols, 2013). Studies using validated neuropsychological measures of central coherence have demonstrated mixed findings, with some showing poor global processing in BDD (Deckersbach et al., 2000;Greenberg et al., 2018), and others not (Hanes, 1998;Monzani et al., 2013). There has been only one metaanalysis to date that has attempted to summarise research findings on global processing deficits in BDD (Johnson, Williamson, & Wade, 2018). ...
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.
Several studies have shown that obsessive-compulsive disorder (OCD), eating disorders (ED), autism spectrum disorders (ASD) and body dysmorphic disorder (BDD) share obsessive-compulsive (OC) symptoms and often co-occur, which could be seen as indicative of a common etiological basis. In addition, they also appear to have similarities in executive functioning. The present study investigated disorder-specific symptoms and executive functioning as a possible joint factor in individuals with OCD (n=53), BDD (n=95), ED (n=171) and ASD (n=73), and in healthy controls (n=110). The participants completed online questionnaires measuring OCD, ED, ASD and BDD related symptoms as well as executive functioning. The clinical groups were first compared to the healthy controls. Subsequently, a network analysis was performed only with the OC-groups. This network approach assumes that psychopathological disorders are the result of causal symptom interactions. As expected, the healthy controls reported less severe symptoms compared to the OC patient groups. The network analysis suggested that the executive functioning skill set shifting/attention switching and the ASD symptoms, social and communication skills were the most central nodes in the model. Difficulty with cognitive flexibility and social factors are central in OC-spectrum disorders and may be perpetuating factors and thus a relevant focus of treatment.
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 seperately 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.
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 (BDD) is a psychiatric diagnosis characterized by a debilitating preoccupation with perceived appearance defects that are not noticeable to others. The International OCD Foundation estimates nearly 1 in 50 individuals in the United States meet the diagnostic criteria for this disorder; however, despite its prevalence, many social work professionals lack familiarity with this diagnosis. Using PRISMA-P reporting guidelines, this article presents a systematic review of studies examining individual, interpersonal, and environmental risks in the development of BDD. Implications for social work practice and suggestions for further research are discussed.
Body Dysmorphic Disorder (BDD) is a mental disorder characterized by a preoccupation with an imagined or slight defect in appearance (eg, shape or size of the nose) that the BDD sufferer perceives as hideous and repulsive. If the individual has a slight physical defect, the concern has to be markedly excessive. Moreover, the preoccupation must cause significant distress or impairment in social or occupational functioning. The concern in appearance also is not better accounted for by another mental disorder (e.g., anorexia nervosa). Research has shown that patients with BDD exhibited significantly poorer performance in both verbal and nonverbal memory tasks, mediated by deficits in organizational strategies. People with BDD believe that appearance is important and that other people notice their imagined or slight flaw in appearance. This may lead to feelings of shame and low self-esteem. Various theorists have incorporated the research on information-processing biases and maladaptive beliefs and attitudes into cognitive-behavior models of BDD's development and maintenance. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Body dysmorphic disorder (BDD) is a poorly understood disorder that involves a preoccupation with imagined or minor bodily defects. Only a few studies of neuropsychological function have been conducted. Two previous studies have indicated executive dysfunction in BDD. The current study sought to further define these executive deficits.
Fourteen DSM-IV BDD patients and 14 age- and sex-matched control participants took part. Because of the high incidence of co-morbidity in BDD, patients with co-morbid Axis I disorders were not excluded. Control participants had no history of psychiatric illness. All participants completed the following executive function (EF) tests: Spatial Span (SS), Spatial Working Memory (SWM) and the Stockings of Cambridge (SOC) task. They also completed the Pattern Recognition (PR) test, a test of visual memory (VM).
BDD participants made significantly more between-search errors on the SWM task, an effect that increased with task difficulty. Between-search errors are an example of poor maintenance and manipulation of information. SOC results indicated slower subsequent thinking times (i.e. the time taken to plan) in BDD participants. There were no group differences in SS or PR scores. The severity of BDD, depressive or anxiety symptoms was not correlated with performance on any of the cognitive tasks.
The results of this study indicate that BDD patients have EF deficits in on-line manipulation, planning and organization of information. By contrast, spatial memory capacity, motor speed and visual memory were intact. Considered with evidence from lesion and neuroimaging studies, these results suggest frontal lobe dysfunction in BDD.
Synopsis
Forty patients with obsessive–compulsive disorder (OCD) were compared to matched healthy controls on neuropsychological tests which are sensitive to frontal lobe dysfunction. On a computerized version of the Tower of London test of planning, the patients were no different from healthy controls in the accuracy of their solutions. However, when they made a mistake, they spent more time than the controls in generating alternative solutions or checking that the next move would be correct. The results suggest that OCD patients have a selective deficit in generating alternative strategies when they make a mistake. In a separate attentional set-shifting task, OCD patients were impaired in a simple discrimination learning task and showed a continuous cumulative increase in the number who failed at each stage of the task, including the crucial extra-dimensional set shifting stage. This suggests that OCD patients show deficits in both acquiring and maintaining cognitive sets.
The cognitive deficits in OCD may be summarized as: (i) being easily distracted by other competing stimuli; (ii) excessive monitoring and checking of the response to ensure a mistake does not occur; and (iii) when a mistake does occur, being more rigid at setting aside the main goal and planning the necessary subgoals. Both studies support the evidence of fronto-striatal dysfunction in OCD and the results are discussed in terms of an impaired Supervisory Attentional System.
Although body dysmorphic disorder (BDD) is receiving increasing empirical attention, very little is known about neuropsychological deficits in this disorder. The current study investigated the nature of memory dysfunction in BDD, including the relationship between encoding strategies and verbal and nonverbal memory performance. We evaluated 17 patients with BDD and 17 healthy controls using the Rey-Osterrieth Complex Figure Test (RCFT) and the California Verbal Learning Test (CVLT). BDD patients differed significantly from healthy controls on verbal and nonverbal learning and memory indices. Multiple regression analyses revealed that group differences in free recall were statistically mediated by deficits in organizational strategies in the BDD cohort. These findings are similar to patterns previously observed in obsessive-compulsive disorder (OCD), suggesting a potential relationship between OCD and BDD. Studies in both groups have shown that verbal and nonverbal memory deficits are affected by impaired strategic processing.
Cognitive performance was compared in the genetically and neurobiologically related disorders of Tourette's syndrome (TS) and obsessive-compulsive disorder (OCD), in three domains of executive function: planning, decision-making and inhibitory response control.
Twenty TS patients, twenty OCD patients and a group of age- and IQ-matched normal controls completed psychometric and computerized cognitive tests and psychiatric rating scales. The cognitive tests were well-characterized in terms of their sensitivity to other fronto-striatal disorders, and included pattern and spatial recognition memory, attentional set-shifting, and a Go/No-go set-shifting task, planning, and decision-making.
Compared to controls, OCD patients showed selective deficits in pattern recognition memory and slower responding in both pattern and spatial recognition, impaired extra-dimensional shifting on the set-shifting test and impaired reversal of response set on the Go/No-go test. In contrast, TS patients were impaired in spatial recognition memory, extra-dimensional set-shifting, and decision-making. Neither group was impaired in planning. Direct comparisons between the TS and OCD groups revealed significantly different greater deficits for recognition memory latency and Go/No-go reversal for the OCD group, and quality of decision-making for the TS group.
TS and OCD show both differences (recognition memory, decision-making) and similarities (set-shifting) in selective profiles of cognitive function. Specific set-shifting deficits in the OCD group contrasted with their intact performance on other tests of executive function, such as planning and decision-making, and suggested only limited involvement of frontal lobe dysfunction, possibly consistent with OCD symptomatology.
There is growing interest in the relationship between anorexia nervosa (AN) and obsessive-compulsive (OC) spectrum disorders (e.g., OCD, body dysmorphic disorder [BDD]). Previous neuropsychological investigations of OC spectrum disorders have identified problems with the efficient use of strategy on complex measures of learning and memory. This study evaluated nonverbal strategic memory in AN outpatients using an approach previously applied to OC spectrum disorders.
Eighteen patients with AN and 19 healthy control participants completed the Rey-Osterrieth Complex Figure Test (RCFT), a widely used measure of nonverbal strategic planning, learning, and memory.
Individuals with AN differed significantly from healthy controls in the organizational strategies used to copy the RCFT figure, and they recalled significantly less information on both immediate and delayed testing. Multiple regression analyses indicated that group differences in learning were mediated by copy organizational strategies.
These results are identical to study findings in OCD and BDD, indicating important shared neuropsychological features among AN and these OC spectrum disorders. As in OCD and BDD, the essential cognitive deficit in AN was impaired use of organizational strategies, which may inform our understanding of the pathophysiology of AN and potentially offer treatment implications.
The aim was to critically appraise and synthesize the literature relating to set-shifting ability in eating disorders. PsycINFO, Medline, and Web of Science databases were searched to December 2005. Hand searching of eating-disorder journals and relevant reference sections was also undertaken.
The 15 selected studies contained both eating disorder and healthy control groups, and employed at least one of the following six neuropsychological measures of set-shifting ability; Trail Making Test (TMT), Wisconsin Card Sort Test (WCST), Brixton task, Haptic Illusion, CatBat task, or the set-shifting subset of the Cambridge Neuropsychological Test Automated Battery (CANTAB). The outcome variable was performance on the set-shifting aspect of the task. Pooled standardized mean differences (effect sizes) were calculated.
TMT, WCST, CatBat and Haptic tasks had sufficient sample sizes for meta-analysis. These four tasks yielded acceptable pooled standardized effect sizes (0.36; TMT -1.05; Haptic) with moderate variation within studies (as measured by confidence intervals). The Brixton task showed a small pooled mean difference, and displayed more variation between sample results. The effect size for CANTAB set shifting was 0.17.
Problems in set shifting as measured by a variety of neuropsychological tasks are present in people with eating disorders.
Objective:
Recent advances in body dysmorphic disorder (BDD) have explored abnormal visual processing, yet it is unclear how this relates to treatment. The aim of this study was to summarize our current understanding of visual processing in BDD and review associated treatments.
Method:
The literature was collected through PsycInfo and PubMed. Visual processing articles were included if written in English after 1970, had a specific BDD group compared to healthy controls and were not case studies. Due to the lack of research regarding treatments associated with visual processing, case studies were included.
Results:
A number of visual processing abnormalities are present in BDD, including face recognition, emotion identification, aesthetics, object recognition and gestalt processing. Differences to healthy controls include a dominance of detailed local processing over global processing and associated changes in brain activation in visual regions. Perceptual mirror retraining and some forms of self-exposure have demonstrated improved treatment outcomes, but have not been examined in isolation from broader treatments.
Conclusion:
Despite these abnormalities in perception, particularly concerning face and emotion recognition, few BDD treatments attempt to specifically remediate this. The development of a novel visual training programme which addresses these widespread abnormalities may provide an effective treatment modality.
{\bf Background.}$ Body dysmorphic disorder (BDD) is a debilitating disorder, characterised by obsessions and compulsions relating specifically to perceived appearance, newly classified within the DSM-5 Obsessive-Compulsive and Related Disorders grouping. Until now, little research has been conducted into the cognitive profile of this disorder. ${\bf Materials~and~Methods.}$ Participants with BDD (n=12) and healthy controls (n=16) were tested using a computerised neurocognitive battery investigating attentional set-shifting (Intra/Extra Dimensional Set Shift Task), decision-making (Cambridge Gamble Task), motor response-inhibition (Stop-Signal Reaction Time Task) and affective processing (Affective Go-No Go Task). The groups were matched for age, IQ and education. ${\bf Results.}$ In comparison to controls, patients with BDD showed significantly impaired attentional set shifting, abnormal decision-making, impaired response inhibition and greater omission and commission errors on the emotional processing task. ${\bf Conclusions.}$ Despite the modest sample size, our results showed that individuals with BDD performed poorly compared to healthy controls on tests of cognitive flexibility, reward and motor impulsivity and affective processing. Results from separate studies in OCD patients suggest similar cognitive dysfunction. Therefore, these findings are consistent with the re-classification of BDD alongside OCD. These data also hint at additional areas of decision-making abnormalities that might contribute specifically to the psychopathology of BDD.
In the past two decades, research advances have enhanced our understanding of the clinical features, cognitive biases, and treatment of body dysmorphic disorder (BDD). In this review, we critically examine the current state of the evidence on the proposed cognitive and emotional processing mechanisms of BDD. We describe how major findings in these areas made unique contributions to the development of an empirically informed cognitive-behavioral model of BDD, which in turn facilitated the translation of research to treatment strategies. Finally, we outline important areas of future research. Expected final online publication date for the Annual Review of Clinical Psychology Volume 11 is March 28, 2015. Please see http://www.annualreviews.org/catalog/pubdates.aspx for revised estimates.
Attentional biases have been implicated in the development and maintenance of BDD. In particular, a visual attention bias toward one's unattractive features and others' attractive features (negative bias), might underlie BDD symptoms. Healthy individuals typically pay more attention to others' unattractive and their own attractive features (positive bias). This study used eye tracking to examine visual attention in individuals with BDD relative to healthy controls (HC). We also explored the role of avoidance in attention bias. Participants with BDD and primary face/head concerns (n = 19) and HC (n = 20) completed computerized tasks and questionnaires. Eye movement data (i.e., fixations, dwell time) were recorded while participants viewed images of their own and a control face (selected for average attractiveness and neutral expression). Participants rated distress and perceived most and least attractive features of their own and another face. BDD participants demonstrated a negative mean total bias score compared to HC (fixation: p = 0.24; dwell: p = 0.08). Age (fixation: p = 0.006; dwell: p = 0.03) and gender (fixation: p = 0.03; dwell: p = 0.03) moderated the relationship. Avoidance was associated with a positive bias in BDD. Results suggest individuals with BDD overfocus on negative attributes, a potential factor in the disorder's etiology and maintenance. Conversely, HC had a more balanced focus on their traits. Elucidating the role of attention bias could help to identify risk and maintenance factors in BDD.
A Monte Carlo study of the distribution of (symmetrically) Winsorized t shows that when the population is normally distributed Winsorized t behaves, to a satisfactory approximation, like a multiple of Student's t with the degrees of freedom that would be assigned intuitively. The approximate multiplier of t is (n – l)/(h – l), where h of the original n observations were not touched by the symmetrical Winsorzation, and the degrees of freedom are h – 1. This approximation is precise enough for most routine uses. More precise values are tabulated.
Anorexia nervosa (AN) and body dysmorphic disorder (BDD) are severe body image disorders that highly impair individuals in their daily functioning. They are discrete but overlapping nosological entities. In this review, we examine similarities between AN and BDD with regard to clinical, personality and demographic aspects, such as comorbidity, phenomenology, and treatment outcome. The review suggests that the two disorders are highly comorbid, and show similar ages of onset, illness trajectories, and comparable clinical and personality characteristics. However, important differences emerge in their responsiveness to psychosocial and psychopharmacological treatment, which are discussed. Clinical implications of these findings are summarized and directions for future research are delineated, with a focus on how current treatment components from each disorder may inform new interventions for both disorders.
Formal genetic studies suggested a substantial genetic influence for Anorexia Nervosa (AN) but currently results are inconsistent. The use of neurocognitive endophenotype approach may facilitate our understanding of the AN pathophysiology. We investigated decision-making, set-shifting and planning in AN patients (n=29) and their unaffected relatives (n=29) compared to healthy probands (n=29) and their relatives (n=29). The Iowa Gambling Task (IGT), the Tower of Hanoi (ToH) and the Wisconsin Sorting Card Test (WCST) were administered. Probands/relatives concordance rates and heritability index were also calculated. Impaired IGT and WCST performances were found in both AN probands and their relatives instead planning appeared to be preserved. IGT heritability index suggested the presence of genetic effects that influence this measure. No evidence for genetic effect was found for WCST. Results suggest the presence of a shared dysfunctional executive profile in women with AN and their unaffected relatives, characterized by deficient decision-making and set-shifting. Concordance analysis strongly suggests that these impairments aggregate in AN families supporting the hypothesis that they may constitute a AN biological markers. Decision-making impairment presents a moderate heritability, suggesting that decision-making may be a candidate endophenotype for AN.
Preoccupation with body shape and weight is characteristic of both anorexia nervosa and bulimia nervosa. Despite their diagnostic and clinical significance, evidence on the nature of the underlying beliefs is relatively scarce. We used the Brown Assessment of Beliefs Scale (BABS) to assess the degree of delusionality of body image beliefs in seventy-two participants: 39 with anorexia and 33 with bulimia nervosa. We also investigated the relationship between body image delusionality and other clinical characteristics in eating disorders. Only patients with anorexia nervosa (28.8%) had delusional body image beliefs, whereas overvalued ideas appeared to be frequent in both anorexia and bulimia nervosa. Body image delusionality in anorexia nervosa was associated with restrictive eating pathology, early onset of the disorder and body dissatisfaction, whereas in the bulimia group it was linked to shorter duration of the illness, more intense dieting behaviors and specific psychological factors: ineffectiveness and maturity fears. Results suggest that a delusional variant of anorexia nervosa represents the one end of a continuum of insight among patients with eating disorders. Categorization of patients with eating disorders based on the level of delusionality of body image beliefs could facilitate further research on the role of insight deficits in these disorders.
Fourteen patients with body dysmorphic disorder (BDD) were assessed with neuropsychological measures, including tests of executive, mnestic, and motor functions. Performance in these patients was compared to 10 patients with obsessive-compulsive disorder (OCD), 14 patients with schizophrenia, and 24 normal controls. Findings indicated normal performance of the BDD group on measures of mnestic and motor function, but poor performance of this group on tests of executive function (p < .05). The overall performance of the BDD and OCD groups on the neuropsychological measures was similar, while the schizophrenic groups showed a wider spectrum of neuropsychological deficits to these groups. These findings are discussed in terms of current theories of executive functions and the possible relationship between BDD and OCD.
The purpose of this study was to investigate the use of the Dysmorphic Concerns Questionnaire (DCQ) as a screening measure for body dysmorphic disorder (BDD) and to derive DCQ cutoff scores to facilitate the screening procedure.
The DCQ was completed by 244 undergraduates (mean = 20.80, SD = 3.10 years) and 57 BDD outpatients (mean = 29.60, SD = 9.44 years) in Melbourne, Australia. The undergraduate sample was screened for eating disorders using the Eating Attitudes Test-26, and for BDD using the Body Dysmorphic Disorder Questionnaire.
The BDD outpatients obtained significantly higher scores on the DCQ than the undergraduates. This difference remained statistically significant after controlling for the severity of depression and social anxiety symptoms. A DCQ cutoff score of 9 resulted in the correct classification of 96.4% of BDD patients and 90.6% of undergraduates.
The results supported the use of the DCQ as a brief, sensitive, and specific screening instrument for BDD.
The authors developed the Yale Brown Obsessive Compulsive Scale Modified for Body Dysmorphic Disorder (BDD-YBOCS), a 12-item semistructured clinician-rated instrument designed to rate severity of body dysmorphic disorder (BDD). The scale was administered to 125 subjects with BDD, and interviews with 15 subjects were rated by 3 other raters. Test-retest reliability was assessed in 30 subjects. Other scales were administered to assess convergent and discriminant validity, and sensitivity to change was evaluated in a study of fluvoxamine. Each item was frequently endorsed across a range of severity. Good interrater reliability, test-retest reliability, and internal consistency were obtained. BDD-YBOCS scores correlated with global severity scores but not with a measure of general psychopathology; they were modestly positively correlated with depression severity scores. Three factors accounted for 59.6 percent of the variance. The scale was sensitive to change in BDD severity. The BDD-YBOCS appears to be a reliable and valid measure of BDD severity and is a suitable outcome measure in treatment studies of BDD.
The authors developed and evaluated the reliability and validity of the Brown Assessment of Beliefs Scale, a clinician-administered seven-item scale designed to assess delusions across a wide range of psychiatric disorders.
The authors developed the scale after reviewing the literature on the assessment of delusions. Four raters administered the scale to 20 patients with obsessive-compulsive disorder (OCD), 20 patients with body dysmorphic disorder, and 10 patients with mood disorder with psychotic features. Audiotaped interviews of scale administration conducted by one rater were independently scored by the other raters to evaluate interrater reliability. The scale was administered to 27 patients twice to determine test-retest reliability. Other insight instruments as well as scales that assess symptom severity were administered to assess convergent and discriminant validity. Sensitivity to change was assessed in a multicenter treatment study of sertraline for OCD.
Interrater and test-retest reliability for the total score and individual item scores was excellent, with a high degree of internal consistency. One factor was obtained that accounted for 56% of the variance. Scores on the Brown Assessment of Beliefs Scale were not correlated with symptom severity but were correlated with other measures of insight. The scale was sensitive to change in insight in OCD but was not identical to improvement in severity.
The Brown Assessment of Beliefs Scale is a reliable and valid instrument for assessing delusionality in a number of psychiatric disorders. This scale may help clarify whether delusional and nondelusional variants of disorders constitute the same disorder as well as whether delusionality affects treatment outcome and prognosis.
It has been suggested that memory impairments found in obsessive-compulsive disorder (OCD) are mediated by organizational problems in encoding that are caused by primary executive dysfunction. Performance on different nonverbal memory and executive skills was tested in 68 subjects (35 non-depressed OCD sufferers and 33 healthy controls). Multiple regression models were performed to analyze the role of different cognitive variables, especially organizational encoding strategies in nonverbal memory. OCD patients performed significantly worse than controls in immediate nonverbal memory [Rey-Osterrieth Complex Figure Test (RCFT)] and on all the executive functions such as interference control (Stroop test), mental set shifting (Trail-Making Test), and organizational strategies (copy organization). As no differences were found in the memory of faces, where organizational strategies are minimal, it is possible to speculate that immediate nonverbal memory problems in OCD appear only when organizational strategies mediate the recalling process. Thus, memory deficits appear to have less to do with memory, per se, and more to do with the degree of organization necessary to effectively complete the task. Statistical analyses of mediation models showed the highest explanatory power for the organizational approach and demonstrated the mediation effect of organizational strategies in nonverbal impairment.
Obsessive compulsive disorder (OCD) is a highly debilitating neuropsychiatric condition with estimated lifetime prevalence of 2-3%, more than twice that of schizophrenia. However, in contrast to other neuropsychiatric conditions of a comparable or lesser prevalence, relatively little is understood about the aetiology, neural substrates and cognitive profile of OCD. Despite strong evidence for OCD being familial, with risk to first-degree relatives much greater than for the background population, its genetic underpinnings have not yet been adequately delineated. Although cognitive dysfunction is evident in the everyday behaviour of OCD sufferers and is central to contemporary psychological models, theory-based studies of neurocognitive function have yet to reveal a reliable cognitive signature, and interpretation has often been confounded by failures to control for co-morbidities. The neuroimaging findings in OCD are amongst the most robust reported in the psychiatric literature, with structural and functional abnormalities frequently reported in orbitofrontal cortex, anterior cingulate cortex, and caudate nucleus. In spite of this, our relative lack of understanding of OCD neurochemical processes continues to impede progress in the development of novel pharmacological treatment approaches. Integrating the neurobiological, cognitive, and clinical findings, we propose that OCD might usefully be conceptualised in terms of lateral orbitofrontal loop dysfunction, and that failures in cognitive and behavioural inhibitory processes appear to underlie many of the symptoms and neurocognitive findings. We highlight existing limitations in the literature, and the potential utility of endophenotypes in overcoming these limitations. We propose that neurocognitive indices of inhibitory functions may represent a useful heuristic in the search for endophenotypes in OCD. This has direct implications not only for OCD but also for putative obsessive-compulsive spectrum conditions including attention deficit hyperactivity disorder, Tourette's syndrome, and trichotillomania (compulsive hair pulling).
The authors examined characteristics of body dysmorphic disorder in the largest sample for which a wide range of clinical features has been reported. The authors also compared psychiatrically treated and untreated subjects. Body dysmorphic disorder usually began during adolescence, involved numerous body areas and behaviors, and was characterized by poor insight, high comorbidity rates, and high rates of functional impairment, suicidal ideation, and suicide attempts. There were far more similarities than differences between the currently treated and untreated subjects, although the treated subjects displayed better insight and had more comorbidity.
To examine central coherence (local and global processing) in women with anorexia nervosa (AN).
42 women with AN and 42 healthy women (HC) completed neuropsychological testing measuring visuospatial and verbal aspects of central coherence: Rey-Osterrieth Complex Figure (RCFT), Embedded Figures Test (EFT), Homograph Reading Test (HRT), and Sentence Completion Task (SCT).
People with AN displayed superior performance on the EFT and poorer performance in RCFT with the exception of accuracy in the copy trial. Long hesitations in the SCT were observed. Verbal coherence tasks were not sensitive enough to detect coherence anomalies in AN.
Women with AN have strengths in tasks requiring local processing (EFT) and weaknesses on tasks benefited by global processing (RCFT and SCT). These results are consistent with the weak central coherence account. This trait might play a role in the maintenance of AN and can be addressed in specific clinical interventions.
Denman Neuropsychology Memory Scale
- S Denman
Denman, S., 1984. Denman Neuropsychology Memory Scale. Charleston, S.C.
The Structured Clinical Interview for the DSM-IV-TR Axis I Disorders, Research Version, Patient Edition (SCID-I/P)
- M B First
- R L Spitzer
- M Gibbon
- J B Williams
First, M.B., Spitzer, R.L., Gibbon, M., Williams, J.B., 2002. The Structured Clinical Interview for
the DSM-IV-TR Axis I Disorders, Research Version, Patient Edition (SCID-I/P). Biometrics
Research. New York State Psychiatric Institute, New York.