Body dysmorphic disorder (BDD) patients are preoccupied with imagined defects or flaws in appearance (e.g., size or shape of nose). They are afraid of negative evaluations by others and often suffer significant morbidity including hospitalization and suicide attempts. Many patients experience ideas of reference, e.g., they often believe others take special notice of their “flaw”.
Facial expressions play an important role in conveying negative or positive feelings, and sympathy or rejection. In this study, we investigated emotion recognition deficits in 18 BDD patients and 18 healthy controls. Participants were presented with two questionnaires accompanying facial photographs. One questionnaire included self-referent scenarios (“Imagine that the bank teller is looking at you. What is his facial expression like?”), whereas the other one included other-referent scenarios (“Imagine that the bank teller is looking at a friend of yours,” etc.), and participants were asked to identify the corresponding emotion (e.g., anger, contempt, neutral, or surprise). Overall, BDD patients, relative to controls, had difficulty identifying emotional expressions in self-referent scenarios. They misinterpreted more expressions as contemptuous and angry in self-referent scenarios than did controls. However, they did not have significantly more difficulties identifying emotional expressions in other-referent scenarios than controls.
Thus, poor insight and ideas of reference, common in BDD, might be related to a bias for misinterpreting other people’s emotional expressions as negative. Perceiving others as rejecting might reinforce concerns about one’s personal perceived ugliness and social desirability.
Body Dysmorphic Disorder (BDD) patients are distressed about imagined or slight physical defects in their appearance, most commonly “flaws” in one’s own face (American Psychiatric Association [APA], 1994). Associated features are frequent checking in mirrors and other reflective surfaces (e.g., store windows) and excessive grooming behaviors (e.g., hair combing, makeup application, or skin picking). Although classified as a somatoform disorder, BDD patients, like sufferers of other anxiety disorders such as social phobia, are often characterized by fear of negative evaluation by others (e.g., Buhlmann et al., 2002a and Hollander et al., 1992). BDD patients, however, are also characterized by a strong fear of appearance-related negative evaluation.
BDD patients may also experience ideas of reference related to their “flaw” (APA, 1994). That is, they are often convinced that others take special notice of the “flaw” and talk about or mock it. If insight is very poor, patients may qualify for an additional diagnosis of delusional disorder, somatic subtype. However, it is possible that both delusional and nondelusional forms of BDD reflect one single disorder with different degrees of insight (Phillips et al., 1994). Moreover, BDD is associated with significant morbidity, including social or occupational impairment, being housebound, hospitalization and suicide attempts (e.g., Phillips et al., 1993).
Previous research has shown that selective information processing might play an important role in the maintenance or etiology of psychological disorders (for review, see Williams et al., 1997). For example, BDD patients, in contrast to healthy controls, selectively attended to BDD-related words such as “attractive” or “ugly”. This may explain why BDD patients are so preoccupied with both their beauty ideal and perceived defect (Buhlmann et al., 2002a). Furthermore, compared to OCD patients and healthy controls, BDD patients interpreted a range of ambiguous situations (BDD-related, social, and general) as threatening, whereas OCD patients only exhibited a negative interpretive bias in ambiguous general situations (Buhlmann et al., 2002b). Thus, it may be that selective processing of threat leads to increased anxiety in these situations, and BDD patients might, as a result, avoid them.
