- Email: [email protected]
Emotion recognition in body dysmorphic disorder: Application of the Reading the Mind in the Eyes Task
Body Image 10 (2013) 247–250
Contents lists available at SciVerse ScienceDirect
Body Image journal homepage: www.elsevier.com/locate/bodyimage
Brief research report
Emotion recognition in body dysmorphic disorder: Application of the Reading the Mind in the Eyes Task Ulrike Buhlmann ∗ , Anna Winter, Norbert Kathmann Humboldt-Universität zu Berlin, Berlin, Germany
a r t i c l e
i n f o
a b s t r a c t
Article history: Received 20 March 2012 Received in revised form 13 December 2012 Accepted 17 December 2012
Body dysmorphic disorder (BDD) is characterized by perceived appearance-related defects, often tied to aspects of the face or head (e.g., acne). Deficits in decoding emotional expressions have been examined in several psychological disorders including BDD. Previous research indicates that BDD is associated with impaired facial emotion recognition, particularly in situations that involve the BDD sufferer him/herself. The purpose of this study was to further evaluate the ability to read other people’s emotions among 31 individuals with BDD, and 31 mentally healthy controls. We applied the Reading the Mind in the Eyes task, in which participants are presented with a series of pairs of eyes, one at a time, and are asked to identify the emotion that describes the stimulus best. The groups did not differ with respect to decoding other people’s emotions by looking into their eyes. Findings are discussed in light of previous research examining emotion recognition in BDD. © 2013 Published by Elsevier Ltd.
Keywords: Body dysmorphic disorder Emotion recognition Reading the mind in the eyes Theory of mind Body image Somatoform disorder
Introduction Facial emotional expressions are an important means to express negative or positive thoughts, feelings, and attitudes such as sympathy and rejection, and researchers have investigated the ability to recognize facial expressions in individuals with psychological disorders such as schizophrenia and social anxiety (e.g., Addington & Addington, 1998; Kerr & Neale, 1993; Simonian, Beidel, Turner, Berkes, & Long, 2001). Given the strong fear of negative evaluation by others and the frequent presence of ideas of reference (e.g., that other people stare at them), individuals with body dysmorphic disorder (BDD; American Psychiatric Association [APA], 2000) might be particularly sensitive to facial expressions. For example, they might interpret a person’s facial expression as negative when it is actually neutral. Further, poor insight and ideas of reference, common in BDD, might be related to a bias for misinterpreting other people’s emotional expressions as threatening, and perceiving others as rejecting might reinforce concerns about one’s personal perceived ugliness and social desirability. Therefore, the ability to recognize facial expressions may play a role in the maintenance or even etiology of disorders that are characterized by strong fears of negative evaluation such as BDD.
∗ Corresponding author at: Humboldt-Universität zu Berlin, Department of Psychology, Rudower Chaussee 18, 12489 Berlin, Germany. Tel.: +49 30 2093 9304; fax: +49 30 2093 4859. E-mail address: [email protected] (U. Buhlmann). 1740-1445/$ – see front matter © 2013 Published by Elsevier Ltd. http://dx.doi.org/10.1016/j.bodyim.2012.12.001
To shed some light on these questions, we assessed emotion recognition in individuals with BDD, relative to individuals with OCD, and mentally healthy controls. Specifically, participants were presented with a series of black and white faces depicting various emotional expressions, one at a time, and were asked to rate each facial expression with respect to its emotional valence. BDD participants, overall, performed poorer in recognizing other people’s emotional expressions, relative to the other groups (Buhlmann, McNally, Etcoff, Tuschen-Caffier, & Wilhelm, 2004). In addition, whereas BDD participants were as accurate as the other groups in identifying angry expressions, they misinterpreted other facial expressions, especially disgusted ones, more often as angry than did the other groups (a common phenomenon which is also often found in healthy individuals, Ekman & Friesen, 1976). However, further analyses indicated that the overall emotion recognition bias for angry expressions still existed after excluding disgusted expressions from the analysis. In other words, this bias was not simply caused by an anger–disgust confusion. We further examined whether individuals with BDD are characterized by a general emotion recognition bias or, more specifically, by a bias restricted to social situations involving themselves (rather than someone else such as a friend; Buhlmann, Etcoff, & Wilhelm, 2006). Thus, we presented the participants with a series of social scenarios displaying a facial stimulus varying in emotional valence as well as a little description of a social situation. The situations were either self-referent (e.g., “Imagine the bank teller is looking in your direction. What is her emotional expression like?”) or other-referent (e.g., “Imagine the bank teller is looking in your friend’s direction. What is her emotional expression like?”). As in
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our previous study, participants were asked to rate each stimulus with respect to its emotional valence. We found that, overall, participants with BDD, relative to mentally healthy controls, had difficulty identifying emotional expressions, although this difference did not reach statistical significance (p = .07, Cohen’s d = 0.64). Further analyses indicated that these deficits were mostly evident in self-referent scenarios, relative to other-referent situations and mentally healthy controls. In addition, they were characterized by a bias to rate neutral faces as threatening (particularly as contemptuous or angry). In sum, there is growing evidence suggesting that BDD is characterized by emotion recognition deficits. The purpose of the current study was to further investigate emotion recognition abilities among individuals with BDD and mentally healthy control participants using the “Reading the Mind in the Eyes” test (RMET; Baron-Cohen, Wheelwright, Hill, Raste, & Plumb, 2001). Specifically, the RMET consists of the presentation of 36 photographs of the eyes depicting complex emotional states (e.g., insecurity, jealousy), and has – to our knowledge – not been used in BDD so far.
Method Participants The BDD group was comprised of 31 individuals (23 females) whose diagnoses were confirmed by the first author administering the structured clinical interview for DSM-IV (SCID; Wittchen, Wunderlich, Gruschwitz, & Zaudig, 1997). BDD symptom severity was assessed with the widely used, clinician-administered Body Dysmorphic Disorder Modification of the Yale-Brown ObsessiveCompulsive Scale (BDD-YBOCS; Phillips, Hollander, Rasmussen, Aronowitz, DeCaria, & Goodman, 1997; Stangier, Hungerbühler, Meyer, & Wolter, 2000). It consists of 12 items that measure the severity of BDD symptoms during the past week. BDD-YBOCS interviews indicated moderate BDD symptom severity in the BDD group (see Table 2). Internal consistency in the current sample was ˛ = .86. Delusionality was assessed using the clinician-administered Brown Assessment of Beliefs Scale (BABS; Eisen, Phillips, Baer, Beer, Atala, & Rasmussen, 1998), which consists of six items assessing the degree of delusionality. The total score ranges from 0 (no delusional thinking) to 24 (complete lack of insight). BABS interviews revealed a mean delusionality score of 16.45 within the BDD group, which indicates poor insight according to the authors’ guidelines (see Table 2). Further, internal consistency in the current sample was ˛ = .87. Primary appearance concerns within the BDD group are depicted in Table 1. Although BDD was the primary diagnosis in all cases (based on symptom severity), SCID interviews revealed the following current comorbid Axis I diagnoses: major depression (n = 15), social phobia (n = 14), specific phobia (n = 8), dysthymia (n = 6), alcohol dependence (n = 3), posttraumatic stress disorder (n = 3), alcohol abuse (n = 1), anorexia nervosa (n = 1), binge eating disorder (n = 1), bipolar disorder, currently depressive episode (n = 1), bulimia nervosa (n = 1), hypochondriasis (n = 1), pain disorder (n = 1), panic disorder without agoraphobia (n = 1), and somatization disorder (n = 1). The control group was comprised of 31 participants (23 females) with no current or past Axis-I psychiatric history, as determined by the SCID. For all groups, a history of psychotic disorders was an exclusion criterion. The groups did not significantly differ with respect to age, t(60) = 0.14, p = .89, d = 0.003, gender, 2 (1) = 0.00, p > .99, and years of education, t(60) = 0.13, p = .89, d = 0.004. All participants were recruited through posted flyers in the greater Berlin area, Germany. Specifically, the BDD groups were recruited through flyers advertising for a research study on body image concerns.
Table 1 Focus of appearance concerns within the body dysmorphic disorder group. Area of appearance concern
Frequency (%)
Skin Hair Breasts Genitals Muscle build Nose Hands Eyes Legs Mouth Buttocks Overall face Ears Stomach Forehead Teeth Back Chin Height Feet Overall appearance
61.3 54.8 35.5 25.8 25.8 25.8 22.6 19.4 19.4 19.4 12.9 9.7 6.5 6.5 6.5 6.5 3.2 3.2 3.2 3.2 3.2
Note. Individuals could report more than one area of concern.
Flyers for the control group advertised for individuals who did not report any current or past psychological problems. Interested study candidates contacted our research group and were provided with a detailed study description by two trained research assistants. If interested, they further underwent a telephone interview asking for specific BDD symptoms according to DSM-IV as well as possible differential diagnoses such as eating disorders, obsessive-compulsive disorder, and social phobia. Measures Questionnaires. Participants completed the following selfreport measures: the Body Dysmorphic Symptoms Inventory (FKS; Fragebogen Körperdysmorpher Symptome; Buhlmann, Wilhelm, Glaesmer, Brähler, & Rief, 2009), and the Beck Depression Inventory-II (BDI-II; Beck & Steer, 1987; Hautzinger, Bailer, Worall, & Keller, 1995). The FKS is an 18 item self-report inventory assessing the severity of body dysmorphic disorder symptoms during the past week. Total scores range from 0 to 64. Internal consistency in the current sample was ˛ = .96. The BDI-II is a widely used 21-item scale examining depressive symptoms during the past two weeks. Total scores range from 0 to 63. Internal consistency in the current sample was ˛ = .96. Reading the Mind in the Eyes Test (RMET). The RMET (BaronCohen et al., 2001) consists of the presentation of 36 images of pairs of eyes expressing complex mental states such as insecurity, jealousy, or hostility. Each photograph is surrounded by four words describing the emotional states. Participants are instructed to choose the emotional state that describes the image best. Further, items can be divided into three categories, varying of emotional valence (positive, negative, and neutral; see Harkness et al., 2005). Total scores range from 0 (no correct answer) to 36 (maximum correct answers). Subscores range from 0 to 12 (negative valence), 0 to 8 (positive valence), and 0 to 16 (neutral valence), depending on the number of items in each category. Internal consistency in the current sample is KR-20 = .64. Procedure The study consisted of two separate visits. During the first visit, following informed consent, participants underwent thediagnostic
U. Buhlmann et al. / Body Image 10 (2013) 247–250
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Table 2 Means and standard deviations by group for demographic and measures related to BDD concerns and the Reading the Mind in the Eyes Task. Measure
BDD group (n = 31) Mean
Age (years) Education (years) Measures BDD-YBOCS BABS FKS BDI-II Emotion recognition RMET-total RMET-positive RMET-negative RMET-neutral
Healthy control group (n = 31) SD
Mean
SD
33.71a 12.23a
9.14 2.32
33.39a 12.16a
9.39 1.12
33.03 16.45 35.19a 24.68a
12.23 5.05 10.74 12.23
– – 4.43b 2.77b
– – 4.77 2.74
25.06a 5.77a 8.16a 11.13a
2.48 1.09 1.85 1.54
25.68a 6.19a 8.10a 11.39a
3.38 1.38 1.97 1.94
Note. BDD-YBOCS = Body Dysmorphic Disorder Modification of the Yale-Brown Obsessive-Compulsive Scale; BABS = Brown Assessment of Beliefs Scale; FKS = Body Dysmorphic Symptoms Inventory; BDI-II = Beck Depression Inventory-II; RMET = Reading the Mind in the Eyes Task; RMET-total = RMET total score; RMET-positive, etc. = RMET valencebased subscores; means sharing subscripts do not differ (ps > .05).
interview to establish BDD status. BDD participants additionally underwent the BDD-YBOCS and BABS interviews after the completion of the SCID. During the second visit, the participants completed the RMET, followed by the remaining questionnaires before being fully debriefed and receiving compensation for their participation. Results BDD-related Beliefs and Associated Symptoms As expected, the BDD group exhibited significantly higher BDD symptoms, as measured with the FKS, t(60) = 14.54, p < .001, d = 3.70, as well as depressive symptoms, as measured with the BDI-II, t(60) = 9.73, p < .001, d = 2.47 (see Table 2). Reading the Mind in the Eyes Test As evident from Table 2, the groups did not significantly differ with respect to the RMET total score, t(60) = 0.81, p = .42, d = 0.21, indicating that the BDD group was as accurate as the control group in decoding emotions from other people’s eyes. Further, no group differences were obtained for the subcategories (negative, positive, and neutral items), ps ≥ .19, d ≤ 0.34. In addition, we examined the degree of delusionality within the BDD group to assess the possible influence of delusionality on emotion recognition. According to the BABS scoring guidelines (see Eisen et al., 1998), 13 participants were classified as having ‘poor insight’, and 11 participants were classified as ‘delusional’. We re-ran the analysis only including the BDD participants that were either delusional or had poor insight (n = 24). Still, no group differences emerged with respect to the RMET total score as well as the subscores, t(53) ≤ 1.29, ps ≥ .20, ds ≤ 0.35, suggesting that delusionality did not have a significant influence on reading emotional states in other people’s eyes. Discussion The purpose of this study was to further evaluate the ability to read other people’s emotions among individuals with BDD and mentally healthy control participants using the RMET (BaronCohen et al., 2001). Interestingly, individuals with BDD were not distinct from the control group with respect to their ability to read other people’s emotional states from their eyes, even when controlling for delusionality. Thus, it is possible that two distinct processes might play a role in BDD when recognizing other people’s emotions. Whereas individuals with BDD might initially be able to correctly identify the emotion, interpretive processes, as a next step, might come into play. Depending on whether or not
the situation isperceived as self-referent, the BDD sufferer might or might not exhibit a negative interpretive bias (e.g., “The person is looking at me in a negative, critical way” versus “The person is looking in a neutral way”). Along these lines, clinical observations also suggest that BDD is characterized by cognitive errors such as the ‘double standard’, which refers to the application of more critical, stricter rules when it comes to oneself (versus to other people). Given the nature of the RMET (i.e., presentation of the eyes only without any further contextual social information), it is possible that the BDD group did not perceive the stimuli as ‘self-referent’ and was consequently as accurate as the healthy control group to decode even complex emotional states. However, the RMET, as used in the current study, does not allow us to draw any firm conclusions regarding the degree of self-reference perceived by the participants. It will be interesting to apply the RMET in future research varying the degree of self-reference by providing additional information about the social context, relative to a control condition that does not provide such information. It should further be noted that the majority of individuals in our BDD sample was diagnosed with additional Axis I disorders (mostly depressive and anxiety disorders). Although it might be interesting to replicate our findings using a BDD sample without any comorbidity, it remains questionable whether such a “pure” BDD sample would be representative for this severe and chronic disorder. Recently, more ecologically valid paradigms such as the Movie for the Assessment of Social Cognition (MASC; Dziobek et al., 2006) have been used to examine the ability to identify thoughts, intentions, and emotions of other people in complex social situations. Thus, we look forward to further examine social cognition in BDD using more innovative and ecologically valid paradigms such as the MASC. Notwithstanding these limitations, our findings suggest that BDD is not associated with a general deficit in emotion recognition, when presented with limited contextual information (i.e., eyes only). Thus, it might be possible that BDD sufferers exhibit a rather specific interpretive emotion recognition bias in situations in which the BDD sufferer feels to be directly involved. This finding is consistent with clinical observations suggesting that individuals with BDD have a ‘double standard’ when it comes to evaluating themselves versus evaluating other people. Gained knowledge about emotion recognition biases and how they may relate to BDD symptoms such as fears of negative evaluation by others might help develop new cognitive intervention techniques such as emotion recognition training programs (see Buhlmann, Gleiß, Rupf, Zschenderlein, & Kathmann, 2011). It will further be interesting to examine whether emotion recognition biases in self-referent situations are related to BDD symptoms (e.g., avoidance of eye contact),
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and how these biases may change over the course of therapy (e.g., as a function of cognitive restructuring and/or specific emotion recognition training). Acknowledgements The project was partly supported by two grants of the German Research Society (DFG), awarded to the first author (BU 1814/7-1, BU 1814/7-2). The authors declare no conflict of interests. References Addington, J., & Addington, D. (1998). Facial affect recognition and information processing in schizophrenia and bipolar disorder. Schizophrenia Research, 32, 171–181. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders-TR. Washington, DC: American Psychiatric Association. Baron-Cohen, S., Wheelwright, S., & Hill, J. (2001). The Reading the Mind in the Eyes Test revised version: A study with normal adults, and adults with Asperger syndrome or high-functioning autism. Journal of Child Psychology and Psychiatry, and Allied Disciplines, 42, 241–251. Beck, A. T., & Steer, R. A. (1987). Manual for the revised Beck Depression Inventory. San Antonio, TX: Psychological Corporation. Buhlmann, U., Etcoff, N. L., & Wilhelm, S. (2006). Emotion recognition bias for contempt and anger in body dysmorphic disorder. Journal of Psychiatric Research, 40, 105–111. Buhlmann, U., McNally, R. J., & Etcoff, N. L. (2004). Emotion recognition deficits in body dysmorphic disorder. Journal of Psychiatric Research, 38, 201–206.
Buhlmann, U., Gleiß, M. J. L., & Rupf, L. (2011). Modifying emotion recognition deficits in body dysmorphic disorder: An experimental investigation. Depression and Anxiety, 28, 924–931. Buhlmann, U., Wilhelm, S., & Glaesmer, H. (2009). Fragebogen körperdysmorpher Symptome (FKS): Ein Screening-Instrument. Verhaltenstherapie, 19, 237–242. Dziobek, I., Fleck, S., & Kalbe, E. (2006). Introducing MASC: A movie for the assessment of social cognition. Journal of Autism and Developmental Disorders, 36, 623–636. Eisen, J. L., Phillips, K. A., & Baer, L. (1998). The Brown Assessment of Beliefs Scale: Reliability and validity. American Journal of Psychiatry, 155, 102–108. Ekman, P., & Friesen, W. (1976). Pictures of facial affect. Palo Alto, CA: Consulting Psychologists Press. Harkness, K. L., Sabbagh, M. A., & Jacobson, J. A. (2005). Enhanced accuracy of mental state decoding in dysphoric college students. Cognition and Emotion, 19, 999–1025. Hautzinger, M., Bailer, M., & Worall, H. (1995). Beck Depressionsinventar. Bern: Huber. Kerr, S. L., & Neale, J. M. (1993). Emotion perception in schizophrenia: Specific deficit or further evidence of generalized poor performance? Journal of Abnormal Psychology, 102, 312–318. Phillips, K. A., Hollander, E., & Rasmussen, S. A. (1997). A severity rating scale for body dysmorphic disorder: Development, reliability, and validity of a modified version of the Yale-Brown Obsessive Compulsive Scale. Psychopharmacology Bulletin, 33, 17–22. Simonian, S. J., Beidel, D. C., & Turner, S. M. (2001). Recognition of facial affect by children and adolescents diagnosed with social phobia. Child Psychiatry and Human Development, 32, 137–145. Stangier, U., Hungerbühler, R., & Meyer, A. (2000). Diagnostische Erfassung der Körperdysmorphen Störung: Eine Pilotstudie. Nervenarzt, 71, 876–884. Wittchen, H. U., Wunderlich, & Gruschwitz. (1997). Strukturiertes Klinisches Interview für DSM-IV – (SKID-I und SKID-II). Göttingen: Hogrefe.
Contents lists available at SciVerse ScienceDirect
Body Image journal homepage: www.elsevier.com/locate/bodyimage
Brief research report
Emotion recognition in body dysmorphic disorder: Application of the Reading the Mind in the Eyes Task Ulrike Buhlmann ∗ , Anna Winter, Norbert Kathmann Humboldt-Universität zu Berlin, Berlin, Germany
a r t i c l e
i n f o
a b s t r a c t
Article history: Received 20 March 2012 Received in revised form 13 December 2012 Accepted 17 December 2012
Body dysmorphic disorder (BDD) is characterized by perceived appearance-related defects, often tied to aspects of the face or head (e.g., acne). Deficits in decoding emotional expressions have been examined in several psychological disorders including BDD. Previous research indicates that BDD is associated with impaired facial emotion recognition, particularly in situations that involve the BDD sufferer him/herself. The purpose of this study was to further evaluate the ability to read other people’s emotions among 31 individuals with BDD, and 31 mentally healthy controls. We applied the Reading the Mind in the Eyes task, in which participants are presented with a series of pairs of eyes, one at a time, and are asked to identify the emotion that describes the stimulus best. The groups did not differ with respect to decoding other people’s emotions by looking into their eyes. Findings are discussed in light of previous research examining emotion recognition in BDD. © 2013 Published by Elsevier Ltd.
Keywords: Body dysmorphic disorder Emotion recognition Reading the mind in the eyes Theory of mind Body image Somatoform disorder
Introduction Facial emotional expressions are an important means to express negative or positive thoughts, feelings, and attitudes such as sympathy and rejection, and researchers have investigated the ability to recognize facial expressions in individuals with psychological disorders such as schizophrenia and social anxiety (e.g., Addington & Addington, 1998; Kerr & Neale, 1993; Simonian, Beidel, Turner, Berkes, & Long, 2001). Given the strong fear of negative evaluation by others and the frequent presence of ideas of reference (e.g., that other people stare at them), individuals with body dysmorphic disorder (BDD; American Psychiatric Association [APA], 2000) might be particularly sensitive to facial expressions. For example, they might interpret a person’s facial expression as negative when it is actually neutral. Further, poor insight and ideas of reference, common in BDD, might be related to a bias for misinterpreting other people’s emotional expressions as threatening, and perceiving others as rejecting might reinforce concerns about one’s personal perceived ugliness and social desirability. Therefore, the ability to recognize facial expressions may play a role in the maintenance or even etiology of disorders that are characterized by strong fears of negative evaluation such as BDD.
∗ Corresponding author at: Humboldt-Universität zu Berlin, Department of Psychology, Rudower Chaussee 18, 12489 Berlin, Germany. Tel.: +49 30 2093 9304; fax: +49 30 2093 4859. E-mail address: [email protected] (U. Buhlmann). 1740-1445/$ – see front matter © 2013 Published by Elsevier Ltd. http://dx.doi.org/10.1016/j.bodyim.2012.12.001
To shed some light on these questions, we assessed emotion recognition in individuals with BDD, relative to individuals with OCD, and mentally healthy controls. Specifically, participants were presented with a series of black and white faces depicting various emotional expressions, one at a time, and were asked to rate each facial expression with respect to its emotional valence. BDD participants, overall, performed poorer in recognizing other people’s emotional expressions, relative to the other groups (Buhlmann, McNally, Etcoff, Tuschen-Caffier, & Wilhelm, 2004). In addition, whereas BDD participants were as accurate as the other groups in identifying angry expressions, they misinterpreted other facial expressions, especially disgusted ones, more often as angry than did the other groups (a common phenomenon which is also often found in healthy individuals, Ekman & Friesen, 1976). However, further analyses indicated that the overall emotion recognition bias for angry expressions still existed after excluding disgusted expressions from the analysis. In other words, this bias was not simply caused by an anger–disgust confusion. We further examined whether individuals with BDD are characterized by a general emotion recognition bias or, more specifically, by a bias restricted to social situations involving themselves (rather than someone else such as a friend; Buhlmann, Etcoff, & Wilhelm, 2006). Thus, we presented the participants with a series of social scenarios displaying a facial stimulus varying in emotional valence as well as a little description of a social situation. The situations were either self-referent (e.g., “Imagine the bank teller is looking in your direction. What is her emotional expression like?”) or other-referent (e.g., “Imagine the bank teller is looking in your friend’s direction. What is her emotional expression like?”). As in
248
U. Buhlmann et al. / Body Image 10 (2013) 247–250
our previous study, participants were asked to rate each stimulus with respect to its emotional valence. We found that, overall, participants with BDD, relative to mentally healthy controls, had difficulty identifying emotional expressions, although this difference did not reach statistical significance (p = .07, Cohen’s d = 0.64). Further analyses indicated that these deficits were mostly evident in self-referent scenarios, relative to other-referent situations and mentally healthy controls. In addition, they were characterized by a bias to rate neutral faces as threatening (particularly as contemptuous or angry). In sum, there is growing evidence suggesting that BDD is characterized by emotion recognition deficits. The purpose of the current study was to further investigate emotion recognition abilities among individuals with BDD and mentally healthy control participants using the “Reading the Mind in the Eyes” test (RMET; Baron-Cohen, Wheelwright, Hill, Raste, & Plumb, 2001). Specifically, the RMET consists of the presentation of 36 photographs of the eyes depicting complex emotional states (e.g., insecurity, jealousy), and has – to our knowledge – not been used in BDD so far.
Method Participants The BDD group was comprised of 31 individuals (23 females) whose diagnoses were confirmed by the first author administering the structured clinical interview for DSM-IV (SCID; Wittchen, Wunderlich, Gruschwitz, & Zaudig, 1997). BDD symptom severity was assessed with the widely used, clinician-administered Body Dysmorphic Disorder Modification of the Yale-Brown ObsessiveCompulsive Scale (BDD-YBOCS; Phillips, Hollander, Rasmussen, Aronowitz, DeCaria, & Goodman, 1997; Stangier, Hungerbühler, Meyer, & Wolter, 2000). It consists of 12 items that measure the severity of BDD symptoms during the past week. BDD-YBOCS interviews indicated moderate BDD symptom severity in the BDD group (see Table 2). Internal consistency in the current sample was ˛ = .86. Delusionality was assessed using the clinician-administered Brown Assessment of Beliefs Scale (BABS; Eisen, Phillips, Baer, Beer, Atala, & Rasmussen, 1998), which consists of six items assessing the degree of delusionality. The total score ranges from 0 (no delusional thinking) to 24 (complete lack of insight). BABS interviews revealed a mean delusionality score of 16.45 within the BDD group, which indicates poor insight according to the authors’ guidelines (see Table 2). Further, internal consistency in the current sample was ˛ = .87. Primary appearance concerns within the BDD group are depicted in Table 1. Although BDD was the primary diagnosis in all cases (based on symptom severity), SCID interviews revealed the following current comorbid Axis I diagnoses: major depression (n = 15), social phobia (n = 14), specific phobia (n = 8), dysthymia (n = 6), alcohol dependence (n = 3), posttraumatic stress disorder (n = 3), alcohol abuse (n = 1), anorexia nervosa (n = 1), binge eating disorder (n = 1), bipolar disorder, currently depressive episode (n = 1), bulimia nervosa (n = 1), hypochondriasis (n = 1), pain disorder (n = 1), panic disorder without agoraphobia (n = 1), and somatization disorder (n = 1). The control group was comprised of 31 participants (23 females) with no current or past Axis-I psychiatric history, as determined by the SCID. For all groups, a history of psychotic disorders was an exclusion criterion. The groups did not significantly differ with respect to age, t(60) = 0.14, p = .89, d = 0.003, gender, 2 (1) = 0.00, p > .99, and years of education, t(60) = 0.13, p = .89, d = 0.004. All participants were recruited through posted flyers in the greater Berlin area, Germany. Specifically, the BDD groups were recruited through flyers advertising for a research study on body image concerns.
Table 1 Focus of appearance concerns within the body dysmorphic disorder group. Area of appearance concern
Frequency (%)
Skin Hair Breasts Genitals Muscle build Nose Hands Eyes Legs Mouth Buttocks Overall face Ears Stomach Forehead Teeth Back Chin Height Feet Overall appearance
61.3 54.8 35.5 25.8 25.8 25.8 22.6 19.4 19.4 19.4 12.9 9.7 6.5 6.5 6.5 6.5 3.2 3.2 3.2 3.2 3.2
Note. Individuals could report more than one area of concern.
Flyers for the control group advertised for individuals who did not report any current or past psychological problems. Interested study candidates contacted our research group and were provided with a detailed study description by two trained research assistants. If interested, they further underwent a telephone interview asking for specific BDD symptoms according to DSM-IV as well as possible differential diagnoses such as eating disorders, obsessive-compulsive disorder, and social phobia. Measures Questionnaires. Participants completed the following selfreport measures: the Body Dysmorphic Symptoms Inventory (FKS; Fragebogen Körperdysmorpher Symptome; Buhlmann, Wilhelm, Glaesmer, Brähler, & Rief, 2009), and the Beck Depression Inventory-II (BDI-II; Beck & Steer, 1987; Hautzinger, Bailer, Worall, & Keller, 1995). The FKS is an 18 item self-report inventory assessing the severity of body dysmorphic disorder symptoms during the past week. Total scores range from 0 to 64. Internal consistency in the current sample was ˛ = .96. The BDI-II is a widely used 21-item scale examining depressive symptoms during the past two weeks. Total scores range from 0 to 63. Internal consistency in the current sample was ˛ = .96. Reading the Mind in the Eyes Test (RMET). The RMET (BaronCohen et al., 2001) consists of the presentation of 36 images of pairs of eyes expressing complex mental states such as insecurity, jealousy, or hostility. Each photograph is surrounded by four words describing the emotional states. Participants are instructed to choose the emotional state that describes the image best. Further, items can be divided into three categories, varying of emotional valence (positive, negative, and neutral; see Harkness et al., 2005). Total scores range from 0 (no correct answer) to 36 (maximum correct answers). Subscores range from 0 to 12 (negative valence), 0 to 8 (positive valence), and 0 to 16 (neutral valence), depending on the number of items in each category. Internal consistency in the current sample is KR-20 = .64. Procedure The study consisted of two separate visits. During the first visit, following informed consent, participants underwent thediagnostic
U. Buhlmann et al. / Body Image 10 (2013) 247–250
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Table 2 Means and standard deviations by group for demographic and measures related to BDD concerns and the Reading the Mind in the Eyes Task. Measure
BDD group (n = 31) Mean
Age (years) Education (years) Measures BDD-YBOCS BABS FKS BDI-II Emotion recognition RMET-total RMET-positive RMET-negative RMET-neutral
Healthy control group (n = 31) SD
Mean
SD
33.71a 12.23a
9.14 2.32
33.39a 12.16a
9.39 1.12
33.03 16.45 35.19a 24.68a
12.23 5.05 10.74 12.23
– – 4.43b 2.77b
– – 4.77 2.74
25.06a 5.77a 8.16a 11.13a
2.48 1.09 1.85 1.54
25.68a 6.19a 8.10a 11.39a
3.38 1.38 1.97 1.94
Note. BDD-YBOCS = Body Dysmorphic Disorder Modification of the Yale-Brown Obsessive-Compulsive Scale; BABS = Brown Assessment of Beliefs Scale; FKS = Body Dysmorphic Symptoms Inventory; BDI-II = Beck Depression Inventory-II; RMET = Reading the Mind in the Eyes Task; RMET-total = RMET total score; RMET-positive, etc. = RMET valencebased subscores; means sharing subscripts do not differ (ps > .05).
interview to establish BDD status. BDD participants additionally underwent the BDD-YBOCS and BABS interviews after the completion of the SCID. During the second visit, the participants completed the RMET, followed by the remaining questionnaires before being fully debriefed and receiving compensation for their participation. Results BDD-related Beliefs and Associated Symptoms As expected, the BDD group exhibited significantly higher BDD symptoms, as measured with the FKS, t(60) = 14.54, p < .001, d = 3.70, as well as depressive symptoms, as measured with the BDI-II, t(60) = 9.73, p < .001, d = 2.47 (see Table 2). Reading the Mind in the Eyes Test As evident from Table 2, the groups did not significantly differ with respect to the RMET total score, t(60) = 0.81, p = .42, d = 0.21, indicating that the BDD group was as accurate as the control group in decoding emotions from other people’s eyes. Further, no group differences were obtained for the subcategories (negative, positive, and neutral items), ps ≥ .19, d ≤ 0.34. In addition, we examined the degree of delusionality within the BDD group to assess the possible influence of delusionality on emotion recognition. According to the BABS scoring guidelines (see Eisen et al., 1998), 13 participants were classified as having ‘poor insight’, and 11 participants were classified as ‘delusional’. We re-ran the analysis only including the BDD participants that were either delusional or had poor insight (n = 24). Still, no group differences emerged with respect to the RMET total score as well as the subscores, t(53) ≤ 1.29, ps ≥ .20, ds ≤ 0.35, suggesting that delusionality did not have a significant influence on reading emotional states in other people’s eyes. Discussion The purpose of this study was to further evaluate the ability to read other people’s emotions among individuals with BDD and mentally healthy control participants using the RMET (BaronCohen et al., 2001). Interestingly, individuals with BDD were not distinct from the control group with respect to their ability to read other people’s emotional states from their eyes, even when controlling for delusionality. Thus, it is possible that two distinct processes might play a role in BDD when recognizing other people’s emotions. Whereas individuals with BDD might initially be able to correctly identify the emotion, interpretive processes, as a next step, might come into play. Depending on whether or not
the situation isperceived as self-referent, the BDD sufferer might or might not exhibit a negative interpretive bias (e.g., “The person is looking at me in a negative, critical way” versus “The person is looking in a neutral way”). Along these lines, clinical observations also suggest that BDD is characterized by cognitive errors such as the ‘double standard’, which refers to the application of more critical, stricter rules when it comes to oneself (versus to other people). Given the nature of the RMET (i.e., presentation of the eyes only without any further contextual social information), it is possible that the BDD group did not perceive the stimuli as ‘self-referent’ and was consequently as accurate as the healthy control group to decode even complex emotional states. However, the RMET, as used in the current study, does not allow us to draw any firm conclusions regarding the degree of self-reference perceived by the participants. It will be interesting to apply the RMET in future research varying the degree of self-reference by providing additional information about the social context, relative to a control condition that does not provide such information. It should further be noted that the majority of individuals in our BDD sample was diagnosed with additional Axis I disorders (mostly depressive and anxiety disorders). Although it might be interesting to replicate our findings using a BDD sample without any comorbidity, it remains questionable whether such a “pure” BDD sample would be representative for this severe and chronic disorder. Recently, more ecologically valid paradigms such as the Movie for the Assessment of Social Cognition (MASC; Dziobek et al., 2006) have been used to examine the ability to identify thoughts, intentions, and emotions of other people in complex social situations. Thus, we look forward to further examine social cognition in BDD using more innovative and ecologically valid paradigms such as the MASC. Notwithstanding these limitations, our findings suggest that BDD is not associated with a general deficit in emotion recognition, when presented with limited contextual information (i.e., eyes only). Thus, it might be possible that BDD sufferers exhibit a rather specific interpretive emotion recognition bias in situations in which the BDD sufferer feels to be directly involved. This finding is consistent with clinical observations suggesting that individuals with BDD have a ‘double standard’ when it comes to evaluating themselves versus evaluating other people. Gained knowledge about emotion recognition biases and how they may relate to BDD symptoms such as fears of negative evaluation by others might help develop new cognitive intervention techniques such as emotion recognition training programs (see Buhlmann, Gleiß, Rupf, Zschenderlein, & Kathmann, 2011). It will further be interesting to examine whether emotion recognition biases in self-referent situations are related to BDD symptoms (e.g., avoidance of eye contact),
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