Introduction
Individuals with Body Dysmorphic Disorder (BDD) may have a propensity for viewing faces differently from healthy controls. In an attempt to explore these processing changes in more detail, we investigate face processing in BDD using two facial recognition tasks; one testing the recognition of facial characteristics, the other testing the recognition of facial expressions of emotion.
Method
Participants with BDD (n=12) and healthy controls (n=16) were tested for inverted face recognition using the Famous Faces Task (FFT) and the Facial Expression of Emotions Stimulus and Test emotion recognition task (FEEST). The groups were matched for age, IQ and education.
Results
Participants with BDD showed a significant ability to correctly recognise inverted famous faces compared to well-matched controls. In contrast, participants with BDD showed a specific deficit in recognising fearful facial emotions. BDD participants excel over controls at performing the FFT.
Conclusions
These findings may represent a cognitive marker for BDD. The specific deficit within the BDD group for recognising fearful expressions may be another feature of the disorder and may implicate abnormal processing of negatively valenced emotional material. The specificity of these findings for BDD merit further investigation using other clinical groups and a larger sample size.
Body Dysmorphic Disorder (BDD), the obsessive preoccupation with perceived defects in appearance, has been estimated to affect 1–2% of the population (Rief, Buhlmann, Wilhelm, Borkenhagen, & Brähler, 2006). Individuals with BDD are concerned they have a bodily imperfection that they consider unsightly, and they fear subsequent negative evaluation by others. In some cases, they exaggerate a trivial flaw; in other cases they are troubled by an imaginary defect. The symptoms of BDD are associated with considerable distress, and in one study (Eisen, Phillips, Coles, & Rasmussen, 2004), as many as 39% of BDD individuals appeared to lack insight into their fixed, false beliefs. Moreover, in an attempt to minimise or hide the defect, or to disconfirm their fears, individuals with BDD engage in time-consuming compulsive behaviours, such as mirror checking (Veale, 2001), applying makeup (camouflaging) and seeking reassurance about their appearance (Goodman et al., 1989). In an attempt to reduce distress, they often engage in social avoidance.
The most common preoccupation in BDD patients is with facial appearance (Phillips, 1996), frequently focusing on specific facial features with which they are unhappy, but also checking the appearance and facial features of others to make comparisons with their own. Grocholewski, Kliem, and Heinrichs (in press) examined eye tracking in individuals with BDD, social anxiety and healthy controls when looking at their own and others' faces. Only patients with BDD showed heightened fixation to an imagined defect in their own face, but also to corresponding regions in unfamiliar faces, supporting the notion of a specific attentional bias in BDD.
Imaging studies point to greater left hemisphere activity thought indicative of greater encoding and analysis of detail as opposed to more holistic and configural processing of faces in BDD (Feusner, Townsend, Bystritsky, & Bookheimer, 2007). Imaging has also documented visual processing and fronto-striatal differences when individuals with BDD are viewing their own face (Feusner et al., 2010c) and that the brain activity in these systems correlates with symptom severity.
Obviously, facial expressions are a key way through which we express positive or negative thoughts, feelings and attitudes. Given the fear of negative evaluation and the frequent ideas of reference (e.g., that others are staring at them), individuals with BDD might be especially sensitive to facial expressions. For example, they might misinterpret a neutral facial expression as negative (Buhlmann et al., 2004 and Buhlmann et al., 2006). Research examining aspects of facial emotion recognition suggests that compared with controls, individuals with BDD have poorer recognition of negatively valenced facial emotions, especially when viewed from their own ‘perspective’ (Williams et al., 1997 and Buhlmann et al., 2002). According to Buhlmann et al. (2004), compared with healthy controls and patients with obsessive-compulsive disorder (OCD), those with BDD show a bias toward misinterpreting facial expressions as angry, including neutral but also disgusted expressions. A later study by Buhlmann et al. (2006) found that individuals with BDD misinterpreted expressions as angry in “self-referent” situations (imagining themselves in a situation) but not in “other-referent” situations. Buhlmann, Gleiss, Rupf, Zschenderlein, and Kathmann (2011) also found that compared to healthy controls and individuals with dermatological conditions, BDD patients were more likely to misinterpret neutral expressions as negative emotions. These findings suggest that individuals with BDD believe other people share their own negative appraisal of their appearance; which might serve to maintain the disorder.
