رابطه نگرانی های بدریخت انگاری بدن و اثرات سرکوب تصویر: مفاهیمی برای مدل های اختلال بدریخت انگاری

A key clinical feature of body dysmorphic disorder (BDD) is the use of avoidance behaviours to minimise discomfort associated with perceived defects in appearance. While overt avoidance, such as avoidance of social situations, has been well-documented (e.g., Phillips, 2005), covert avoidance, such as image suppression, has not been explored. This study investigated the role of suppression of negative self-imagery in the maintenance of dysmorphic concern. Undergraduate participants completed a thought suppression paradigm with an experimentally-constructed negative self-image as the target. Dysmorphic concern was associated with how distressing and vivid an appearance-related intrusion was, although it did not affect whether participants engaged in suppression of the intrusion. Instructions to suppress the image led to reduced intrusion frequency and discomfort but it did not affect the quality (e.g., vividness) of intrusions. In addition, participants high in dysmorphic concern were more likely to internalise distorted appearance-related information and be disgusted by that information. Implications for models of body dysmorphic disorder are discussed.

Body dysmorphic disorder (BDD) is a disorder characterised by a distressing or impairing preoccupation with a perceived defect in appearance that is often accompanied by repetitive or compulsive behaviour directed toward the defect. BDD shares many similarities with OCD in clinical features, demographic features, psychiatric comorbidity and similar treatment response to serotonin reuptake inhibitor medication (e.g., Phillips et al., 2007). For this reason BDD has widely been considered to be an OCD spectrum disorder. BDD patients have been found to engage in a number of behavioural avoidance strategies intended to reduce anxiety and other negative emotional states associated with negative judgements of their own appearance (e.g., Didie, Kelly, & Phillips, 2010). While these overt avoidance patterns, such as mirror avoidance and social withdrawal, have been well-documented, more covert methods of avoidance have not yet been investigated. Thought suppression is one such method by which individuals with BDD may attempt to avoid internal reminders of their appearance flaws. BDD patients have been shown to report more vivid and negative intrusive appearance-related images that are viewed from an observer (third-person) perspective compared to controls (Osman, Cooper, Hackmann, & Veale, 2004). In addition, preliminary data from our laboratory suggests that body dysmorphic disorder patients and undergraduates high in dysmorphic concern engage in more suppression of appearance-related imagery than anxious control participants and undergraduates lower in dysmorphic concern (Onden-Lim & Grisham, Unpublished). We posit that suppression of these appearance-related images may contribute to the maintenance of the disorder. A large body of research on thought suppression suggests that efforts to suppress unwanted cognitions are likely to be ineffective and ultimately maladaptive, since unwanted thoughts can paradoxically increase after a period of suppression (Abramowitz et al., 2001 and Wenzlaff and Wegner, 2000). Furthermore, increases in target thought frequency are often accompanied by negative emotions such as frustration and distress, which in turn fuel further suppression efforts and other avoidance behaviours (Purdon, 1999 and Salkovskis and Campbell, 1994). These mechanisms have been shown to play a major role in the maintenance of other disorders (e.g., Purdon, 1999 and Purdon et al., 2005). Much of this previous thought suppression research, however, has failed to distinguish between cognitions that are primarily verbal in nature and those that are imagery-based. Semantic and imagery-based cognitions differ qualitatively (Paivio, 1971) and in their relation with memories and emotions (Holmes and Mathews, 2010 and Holmes et al., 2008). The verbal thought-imagery distinction may be particularly important in BDD since appraisals about the self are often based on internal perceptual representations of actual and ideal selves (Veale & Neziroglu, 2010). Furthermore, imagery appears to be more closely tied to the affective system than verbal thoughts (Holmes & Mathews, 2010). Thus, the overarching aim of the current study was to conduct a preliminary investigation of the role of suppression of negative self-images in the maintenance of BDD. In order to accomplish this aim, we induced negative self-images in an undergraduate population using a distorted photograph of each participant. First, we examined the association between level of dysmorphic concern and reaction to the negative self-image prior to any explicit instructions. Second, we investigated the effect of experimental instructions to suppress the induced negative self-imagery. We hypothesised that dysmorphic concern would predict more frequent intrusions of negative self-imagery, more efforts to suppress that imagery, and more discomfort experienced during intrusions. We also predicted that higher dysmorphic concern would be associated with more vivid, longer intrusions and more use of the observer perspective in line with Osman et al.'s (2004) study, as well as more disgust toward and reported believability of the negative self-imagery. Disgust and believability of an induced negative self-image were introduced as additional variables based on BDD case reports of high levels of reported disgust toward appearance and the tendency for patients to use distorted non-mirror reflecting surfaces for feedback about the appearance (Phillips, 2005 and Veale and Riley, 2001). We predicted that the above associations would remain significant controlling for general psychopathology and baseline mood. Consistent with previous thought suppression research (e.g., Abramowitz et al., 2001), we hypothesised that suppression of negative self-imagery would result in more frequent intrusions in the post-suppression period, and more discomfort experienced during intrusions both during and after the suppression period. We also predicted that suppression would decrease the duration of intrusions, since they would be terminated earlier, but not affect their quality (vividness and perspective).

In sum, the present study demonstrated a possible role for suppression of appearance-related imagery in BDD, and provided some initial evidence as to the nature of internal distorted appearance-related imagery. A noteworthy contribution of this study is the use of a novel, standardised facial disfigurement added to participants' photographs to serve as a component of the suppressed imagery. This approach permitted greater experimental control over the target concern because participants did not have direct (only related) prior experiences with that concern. However, in order to increase applicability of the concern to participants, it would be useful for future studies to complement such studies by using idiosyncratic concerns as part of the suppressed imagery.