حساسیت طرد شخصی و مبتنی بر ظاهر در اختلال بدریخت انگاری

Although rejection sensitivity may be an important feature of body dysmorphic disorder (BDD), no studies have examined rejection sensitivity in a clinical sample and compared types of rejection sensitivity in individuals with BDD. Personal and appearance-based rejection sensitivity scores in forty-six patients diagnosed with BDD were compared with published norms. Associations between rejection sensitivity, BDD severity, and other clinical variables were examined. Personal and appearance-based rejection sensitivity scores were 0.6 and 1.1 standard deviation units above published norms, respectively. Greater personal rejection sensitivity was associated with more severe BDD and depressive symptoms, poorer mental health, general health, and physical and social functioning. Greater appearance-based rejection sensitivity was associated with more severe BDD and depressive symptoms, and poorer general health. Appearance-based rejection sensitivity contributed more unique variance to BDD severity than personal rejection sensitivity did; however, personal rejection sensitivity contributed more unique variance to general health than appearance-based rejection sensitivity did.

Body dysmorphic disorder (BDD) is an often severe psychiatric disorder characterized by time-consuming preoccupations with one or more perceived defects or flaws in appearance that are not observable or appear slight to others. BDD-related preoccupations cause clinically significant distress or impairment in functioning and, at some point during the course of the disorder, are accompanied by repetitive behaviors or mental acts that occur in response to the appearance preoccupations (e.g., mirror checking, skin picking, excessive grooming, comparing with others) (American Psychiatric Association, 2013 and Phillips, 2005). Using a variety of measures, studies have consistently found marked impairment in psychosocial functioning and quality of life in BDD (IsHak et al., 2012, Phillips, 2000 and Phillips et al., 2005a). For example, in a prospective study of psychosocial functioning in BDD, the cumulative probability of attaining functional remission on the Social and Occupational Functioning Assessment Scale (APA, 2000) over a mean follow-up period of 2.7 ± 0.9 years was only 10.6% (Phillips, Quinn, & Stout, 2008). Social functioning in BDD appears particularly poor. Mean Overall Social Adjustment total scores on the Social Adjustment Scale Self-Report (SAS-SR) are more than two standard deviation (SD) units below community norms ( Phillips, Menard, Fay, & Pagano, 2005). Social Functioning subscale scores on the Medical Outcomes Study Short Form Health Survey (SF-36) are 0.4 SD units poorer than norms for depression ( Phillips, Menard, Fay, & Pagano, 2005). Levels of social anxiety are associated with poorer psychosocial functioning over 12 months in individuals with BDD without comorbid social anxiety disorder, particularly fear and avoidance of social situations ( Kelly, Walters, & Phillips, 2010). In addition, BDD is associated with severe interpersonal problems, particularly related to difficulties with being assertive and high levels of social inhibition ( Didie, Loerke, Howes, & Phillips, 2012). One possible reason for social and interpersonal problems among individuals with BDD is their tendency to be distressed if they perceive that others are negatively evaluating them. In one BDD study, one of the most frequently endorsed personality disorder criteria was being easily hurt by criticism and feeling embarrassment and shame in association with perceived criticism (Phillips & McElroy, 2000). A previous report found that individuals with BDD who were ascertained for major depressive disorder had high levels of personal rejection sensitivity (Phillips, Nierenberg, Brendel, & Fava, 1996). That is, they tended to be worried that others would negatively evaluate them and reject them. Clinical observations additionally suggest that personal rejection sensitivity is common in persons with BDD (Phillips, 2005). Despite the apparent importance of personal rejection sensitivity in BDD, studies of this topic are limited. One study found that personal rejection sensitivity as assessed by the Rejection Sensitivity Questionnaire (Downey & Feldman, 1996) partially mediated the relationship between social anxiety symptoms and body dysmorphic concerns in sample of undergraduates (Fang, Asnaani, Gutner, Cook, Wilhelm, & Hofmann, 2011). This finding suggests that personal rejection sensitivity may be an independent but related construct associated with social anxiety in BDD. However, this cross-sectional study was in done in an undergraduate student sample that was administered the Body Dysmorphic Disorder Symptoms Scale (BDD-SS; Wilhelm, 2006 and Wilhelm et al., 2013), which is not a diagnostic measure, rather than in individuals who were identified on the basis of a clinical interview as having a diagnosis of BDD. A more specific type of rejection sensitivity, appearance-based rejection sensitivity, may also be a key characteristic of BDD. Appearance-based rejection sensitivity is defined as anxiety-provoking expectations of social rejection based on physical appearance (Park, 2007). From a clinical perspective, individuals with BDD often report that they avoid social situations because they fear that other people will negatively evaluate their appearance (Kelly et al., 2010). Furthermore, in a sample of college students, levels of appearance-based rejection sensitivity were positively associated with self-reported BDD symptoms on the Body Dysmorphic Disorder Questionnaire and with acceptance of cosmetic surgery (Calogero et al., 2010 and Park et al., 2009) even after controlling for levels of personal rejection sensitivity. In addition, a recent study of individuals with BDD in mental health treatment or support groups found that these individuals reported high levels of anxiety associated with their perceptions of their appearance and perceptions of others regarding their appearance, as well as anxiety related to negative evaluation of their appearance (Anson, Veale, & de Silva, 2012). Thus, appearance-based rejection sensitivity may be an important feature of BDD. Despite the apparent importance of rejection sensitivity in BDD, particularly appearance-based rejection sensitivity, prior studies are limited to analog samples. To our knowledge, no studies have evaluated appearance-based rejection sensitivity and personal rejection sensitivity in a sample diagnosed with BDD. Furthermore, all studies to date were conducted in undergraduate students, which limits the samples’ representativeness in terms of age and other demographic variables. In addition, prior studies have not examined the association of personal rejection sensitivity and appearance-based rejection sensitivity with BDD severity and other clinical correlates in a sample diagnosed with or ascertained for BDD. Although rejection sensitivity appears to be an important characteristic of BDD, to our knowledge, current BDD treatment approaches do not specifically target rejection sensitivity. If rejection sensitivity appears to be highly associated with BDD symptoms and psychosocial functioning, the inclusion of treatment approaches that specifically target rejection sensitivity (either personal or appearance-based) may improve psychosocial treatment approaches for BDD. Therefore, the purpose of the present study is to provide information on associations between appearance-based rejection sensitivity and personal rejection sensitivity and clinical correlates of BDD. Based on the studies described above, as well as our clinical experience with BDD, we expected both personal and appearance-based rejection sensitivity would be positively associated with BDD symptom severity and severity of depressive symptoms, and negatively associated with psychosocial functioning. However, given appearance-based rejection sensitivity's direct relevance to BDD symptoms and presentation, we expected appearance-based rejection sensitivity to have stronger associations with BDD severity, severity of depressive symptoms, and psychosocial functioning than personal rejection sensitivity.