Article

Set shifting and visuospatial organization deficits in body dysmorphic disorder

Authors:
  • Massachusetts General Hospital/Harvard Medical School
  • Massachusetts General Hospital/ Harvard Medical School
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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.

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... 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). ...
Article
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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. ...
Thesis
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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. ...
Article
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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). ...
Article
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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). ...
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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.
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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.
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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.
Article
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.
Article
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.
Article
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.
Article
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.
Article
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.
Article
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).
Article
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.
Article
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.