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.
Body dysmorphic disorder (BDD) is characterized by preoccupation with a perceived defect in one's appearance that causes clinically significant distress and/or functional impairment. BDD is common, affecting an estimated 1.7–2.4% of the population (Buhlmann et al., 2010; Koran et al, 2008; Rief et al., 2006). Thus, identification of risk factors and effective treatment strategies are critical.
Cognitive models of BDD (e.g., Veale, 2004 and Wilhelm et al., 2013) implicate attention bias in its etiology and maintenance. Individuals with BDD selectively attend to specific aspects of one's appearance or minor appearance flaws. This is supported by clinical observations and neurocognitive (e.g., functional magnetic resonance imaging [fMRI]) research findings demonstrating a bias for detailed rather than holistic elements of visual stimuli (Deckersbach et al., 2000, Feusner et al., 2007, Feusner et al., 2010a and Feusner et al., 2010b). For example, using fMRI to examine information processing in BDD, Feusner et al., 2007 and Feusner et al., 2010b found that BDD patients over-utilized the detail-oriented left hemisphere (local processing) compared to controls when exposed to pictures of neutral and their own faces. Increased attention to detail can lead individuals with BDD to overfocus on, and overemphasize the importance of, minor or perceived imperfections in appearance, thereby maintaining and worsening appearance related distress. BDD patients overestimate the importance of perceived imperfections and falsely interpret them as reflective of personal defectiveness and lack of self-worth (Veale et al., 1996) (e.g., “unless I have perfect skin, nobody will ever love me”). Patients react to perceived flaws and related self-defeating interpretations with negative emotions (e.g., anxiety, depression, shame) that further increase selective attention. In an attempt to fix perceived flaws and/or alleviate distress, individuals with BDD engage in time-consuming rituals, including excessive mirror checking (e.g., getting “stuck” in front of the mirror for hours per day) and comparing their own appearance to that of others. In comparison to independent evaluations by individuals without appearance concerns, individuals with BDD tend to underestimate their own attractiveness, yet overestimate the attractiveness of other individuals (Buhlmann et al., 2008). Persons with BDD also often avoid social and other trigger situations (e.g., mirrors, eye contact). Feusner et al. (2007) suggested that aberrant emotional information processing in BDD may be mediated by early stage (visual) processing biases. However, past methodologies make it difficult to extricate direct attention processes from verbal stimuli/responses.
Eye tracking provides an opportunity to explore direct attention processes; this approach has been used to study cognitive factors in individuals with eating disorder symptomatology (e.g., Blechert et al., 2010, Jansen et al., 2005, Roefs et al., 2008 and Smeets et al., 2011). Findings from these studies with eating disordered individuals suggest that individuals high in body dissatisfaction attend more to their own perceived unattractive features and to the perceived attractive features of others (negative attention bias), whereas healthy controls (HC) demonstrate a positive cognitive bias (i.e., selectively attend to their perceived most attractive part and to the most unattractive part of others). These data demonstrate a tendency toward a negative attention bias among individuals high in body dissatisfaction, and suggest that a negative attention bias may maintain or even play a role in the etiology of body dissatisfaction (Jansen et al., 2005 and Smeets et al., 2011). Grocholewski et al. (2012) used eye tracking to demonstrate selective attention among BDD patients to parts of concern on their own face and corresponding regions in the faces of unfamiliar individuals. However, this study did not use a validated set of facial stimuli, nor did it allow for examination of avoidance of attractive and unattractive stimuli; avoidance is a prominent feature of BDD, and many patients fluctuate between mirror checking and mirror avoidance (Veale and Riley, 2001).
