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Non-weight-related body image concerns and Body Dysmorphic Disorder prevalence in patients with Anorexia Nervosa
Psychiatry Research 267 (2018) 120–125
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Non-weight-related body image concerns and Body Dysmorphic Disorder prevalence in patients with Anorexia Nervosa
T
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Silvia Cereaa, , Gioia Bottesia, Jessica R. Grishamb, Marta Ghisia a b
Department of General Psychology, University of Padova, Padova, Italy School of Psychology, University of New South Wales, Sydney, Australia
A R T I C LE I N FO
A B S T R A C T
Keywords: Anorexia Nervosa Body Dysmorphic Disorder Psychological features Psychopathological features
Patients with Anorexia Nervosa (AN) and patients with Body Dysmorphic Disorder (BDD) are both characterized by body image disturbance and dissatisfaction; furthermore, these disorders share clinical features and frequently co-occur. However, few studies have explored the relation between AN and BDD. Therefore, the first aim of the study was assessing the prevalence of BDD and presence of non-weight-related body image concerns in patients with AN. Second, we were interested in comparing patients with AN and non-weight-related body image concerns, patients with weight-related body image concerns only, and a healthy control group with respect to several psychological and psychopathological features. Sixty-one female patients with AN were divided in two subgroups: 39 with non-weight-related body image concerns and 22 with weight-related body image concerns only. Sixteen (26.23%) patients with AN had probable comorbid BDD. Moreover, patients with AN and nonweight-related body image concerns reported, overall, greater psychopathology than patients with AN and weight-related body image concerns only, with the exception of AN core features and general distress. In conclusion, patients with AN and non-weight-related body image concerns showed a more severe body image disturbance unrelated to a more severe eating disorder pathology.
1. Introduction Body Dysmorphic Disorder (BDD) is a psychiatric condition characterized by concerns regarding one or more perceived defects in physical appearance that are not observable to others (American Psychiatric Association, 2013). Appearance concern is often focused on skin, hair, and nose (Phillips and Diaz, 1997; Phillips et al., 1993; Veale et al., 1996); however, it may involve any body areas (Veale, 2000) and individuals with BDD may be simultaneously concerned with multiple body parts (Phillips et al., 2005). Because the essential pathology of BDD is a disturbance in body image (Rosen and Ramirez, 1998), it has been suggested that BDD might be better clustered under an encompassing ‘body image disorder’ category, along with Eating Disorders (EDs; Mitchison et al., 2013; Phillipou et al., 2015, 2017); however, data from a recent study did not support this cluster in male and female adolescents (Schneider et al., 2018). Both BDD and EDs are severe body image disorders (Rosen et al., 1995) characterized by body image disturbance and dissatisfaction. Moreover, BDD and EDs share clinical features (Grant and Phillips, 2004): both disorders are characterized by dissatisfaction about appearance and by an overemphasis on appearance in the
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Corresponding author. E-mail address: [email protected] (S. Cerea).
https://doi.org/10.1016/j.psychres.2018.05.068 Received 27 November 2017; Received in revised form 22 May 2018; Accepted 26 May 2018 Available online 31 May 2018 0165-1781/ © 2018 Elsevier B.V. All rights reserved.
evaluation of self-worth (Rosen and Ramirez, 1998). Furthermore, both disorders are characterized by similar onset and course, cognitive characteristics (such as information processing deficits), and personality traits, such as high levels of perfectionism and low self-esteem (Hartmann et al., 2013). Due to this considerable overlap, distinguishing between BDD and EDs is sometimes challenging (Dingemans et al., 2012). However, people with EDs focus primarily on body weight and shape, whereas people with BDD focus on specific body parts (Phillips et al., 1995); nevertheless, high rates of dissatisfaction with body areas unrelated to weight or shape (non-weightrelated body image concerns, NWRCs) can characterize patients with EDs (Kollei et al., 2013), and concerns related to body shape and weight can characterize patients with BDD (Ruffolo et al., 2006) and Muscle Dysmorphia (MD; Pope et al., 1997). MD is subtype of BDD characterized by the preoccupation with the idea that one's body is not sufficiently lean and muscular (APA, 2013; Pope et al., 1997; Pope et al., 2000); the core feature of MD resembles those of eating disorders, particularly anorexia nervosa (AN), in that a disturbed perception of body image is present (Phillipou et al., 2015). Furthermore, both disorders are characterized by compulsive exercise and rigid diet (Olivardia et al., 2000; Nieuwoudt et al., 2015).
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Table 1 Diagnostic criteria for BDD (DSM-5; American Psychiatric Association, 2013). Description of DSM-5 criteria
Item
A. Preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others.
1. Are you concerned about the presence of one or more perceived defects in your physical appearance that are not observable or appear slight to others? If yes, please list the area(s) of concern and the degree of dissatisfaction with each area(s) 2. Do you perform repetitive behaviours (e.g. mirror checking, skin picking, reassurance seeking) or mental acts (e.g. comparing appearance with that of others) in response to the appearance concerns?
B. At some point during the course of the disorder, the individual has performed repetitive behaviours (e.g., mirror checking, excessive grooming, skin picking, reassurance seeking) or mental acts (e.g., comparing his or her appearance with that of others) in response to the appearance concerns C. The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
3. Does the preoccupation about your physical defect(s) cause you significant distress or impairment in your everyday life? Does the preoccupation about your physical defect(s) caused you significant impairment in your social activities? If yes: Please describe how. Does the preoccupation about your physical defect(s) caused you significant problems with school, work, or other activities? If yes: Please describe how. Are there things you avoid because of the preoccupation about your physical defect (s)? If yes: Please describe how. 4. Is your weight or shape the primary cause of your appearance concerns?
D. The appearance preoccupation is not better explained by concerns with body fat or weight in an individual whose symptoms meet diagnostic criteria for an eating disorder.
Note. A positive screen for BDD is obtained if participants report positive answers to questions one, two and three. Moreover, a negative answer to question number four is required.
presence of NWRCs in patients with AN in accordance with DSM-5 (APA, 2013) diagnostic criteria for BDD. We chose to restrict our investigation to patients with AN in light of the similarities between AN (rather than BN) and BDD in terms of severity, onset and course, and clinical features (Hartmann et al., 2013). It represents the first study aimed at comparing patients with AN and NWRCs with patients with AN and weight-related body image concerns (WRCs) only with respect to BDD symptoms, core features of EDs, obsessive-compulsive (OC) symptoms, general distress, social anxiety symptoms, and self-esteem. Furthermore, both clinical groups were compared with a healthy control (HC) group. Similar to previous studies (Dingemans et al., 2012; Grant et al., 2002; Kollei et al., 2013), we expected high BDD prevalence and high presence of NWRCs in patients with AN (Dingemans et al., 2012; Grant et al., 2002). Furthermore, we expected that patients with AN and NWRCs would show higher levels of psychological and psychopathological symptoms and lower self-esteem than patients with AN and WRCs only and the HC group.
The current hierarchical organization of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5; APA, 2013) stipulates that a diagnosis of BDD cannot be provided if appearance concerns are better explained by concerns with body fat or weight in an individual whose symptoms meet diagnostic criteria for EDs (APA, 2013); this frequently results in not diagnosing BDD when patients fulfill the criteria for EDs (Dingemans et al., 2012). So far, only a few studies have investigated the prevalence of BDD and the presence of NWRCs in patients with EDs, and found high comorbidity of BDD and EDs, as well as high presence of NWRCs (Dingemans et al., 2012; Grant et al., 2002; Kollei et al., 2013; Ruffolo et al., 2006). However, the majority of these studies share similar shortcomings. For example, the study by Grant et al. (2002), conducted on 41 inpatients with Anorexia Nervosa (AN), did not include a control group and did not investigate the possibility of a more severe EDs pathology in patients with AN and comorbid BDD. Authors found that patients with AN and comorbid BDD were dissatisfied with their nose, skin, hair, chin, lips, and eyes, and that they were three times more likely to have attempted suicide secondary to appearance concerns than those without comorbid BDD (Grant et al., 2002). The study by Kollei et al. (2013) found that 14.3% of patients with Bulimia Nervosa (BN) and 9.8% of patients with AN met criteria for BDD; the most commonly reported areas of concern were skin, arms, eyebrows, and nose. However, authors did not include a control group and participants were only inpatients with EDs. The study by Dingemans et al. (2012) found that 45% of patients with EDs (n = 158) probably suffered from BDD, and that inpatients with comorbid BDD referred earlier onset of AN, greater severity of EDs pathology, and general symptomatology than those without comorbid BDD. However, control group was lacking and the presence of NWRCs was not explored. Despite the above-mentioned limitations, these studies underlined the importance of assessing the prevalence of BDD and the presence of NWRCs (which can be conceptualized as subclinical manifestation of BDD) in patients with EDs (Dingemans et al., 2012; Kollei et al., 2013; Grant et al., 2002). Indeed, the presence of NWRCs in patients with EDs confers additional severity in terms of clinical symptomatology (Dingemans et al., 2012; Kollei et al., 2013; Grant et al., 2002). To note, failures in diagnosing BDD and NWRCs in patients with EDs may have important treatment implications, since standard EDs programs focus almost exclusively on eating pathology and are usually less effective in treating body image compared to eating pathology (Ferrer-García and Gutiérrez-Maldonado, 2012; Perpiñá et al., 1999). The current study aimed at assessing the prevalence of BDD and the
2. Methods 2.1. Participants Sixty-one female patients suffering from AN entered the study. Diagnostic status was ascertained using the Structured Clinical Interview for Axis I Disorders, Patient Edition (SCID-I/P; First et al., 2002). Inclusion criteria for all participants were meeting criteria for current AN and being aged at least 18 years old. Exclusion criteria were the existence of severe neurological diseases, current or past psychotic disorders, and mental retardation. All patients were in treatment (57.4% inpatient and 42.6% outpatient/day hospital) and most of them (68.85%) were medicated: fluoxetine and sertraline were the most represented medications. Patients with AN were divided, according to the presence of NWRCs (Table 1), in two subgroups: patients with WRCs only (AN-only; N = 22) and patients with NWRCs (AN + NWRC; N = 39). An additional group of 61 HCs was recruited. None of the HCs met diagnostic criteria for any current psychiatric disorder and none were taking any psychiatric medications. Groups were equivalent with respect to age and years of education (Table 2), whereas significant differences on Body Mass Index (BMI) emerged: Bonferroni post hoc comparisons revealed that the BMI of both clinical groups was lower than the BMI of the HC group (p < 0.001), whereas no differences between clinical 121
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Table 2 Comparisons among patients with Anorexia Nervosa (AN) and weight-related body image concerns only (AN-only group), patients with AN and non-weight-related body image concerns (AN + NWRC group), and healthy controls (HC group) on age, years of education and Body Mass Index (BMI).
Age Years of education BMI
AN-only (1) (N = 22) M (SD)
AN + NWRC (2) (N = 39) M (SD)
HC (3) (N = 61) M (SD)
F
28 (10.12) 12.73 (3.64) 16.68 (2.38)
24.56 (8.81) 12.84 (2.54) 16.32 (2.41)
25.97 (9.34) 12.98 (2.48) 22.02 (3.12)
0.96 0.08 61.19
(2,119)
p
η2p
Post-hoc
0.39 0.92 <0.001
– – 0.51
– – 1=2<3
Table 3 Frequencies of occupation and marital status of patients with Anorexia Nervosa (AN) and weight-related body image concerns only (AN-only group), patients with AN and non-weight-related body image concerns (AN + NWRC group) and healthy controls (HC group). Occupation
AN-only (N = 22)
AN + NWRC (N = 39)
HC (N = 61)
Marital status
AN-only (N = 22)
AN + NWRC (N = 39)
HC (N = 61)
Student Full time employed Part time employed Unemployed Other
9 2 0 8 2
21 6 4 5 3
37 9 5 0 7
Single In a relationship Married
14 3 5
27 7 4
20 29 12
distress) have been demonstrated to yield redundant information (e.g., Foa et al., 2002). For the purpose of the current study we focused only on the total score of the questionnaire. In the present study, the alpha coefficient for the total OCI distress was α = 0.96. The Depression Anxiety Stress Scale-21 (DASS-21; Lovibond and Lovibond, 1995; Bottesi et al., 2015): a 21-item measure assessing depression, anxiety, and stress on a 4-point Likert scale. Three subscale scores as well as a total score can be computed (Bottesi et al., 2015). The Italian DASS-21 showed adequate reliability. Given that findings on the Italian version suggested that use of the total score, measuring a “general distress” factor, could be more appropriate than calculating the three subscale scores separately (Bottesi et al., 2015), for the purpose of the presence research we focused only on the total score of the questionnaire. In the present study, the alpha coefficient for the total DASS-21 was excellent (α = 0.95). The Social Interaction Anxiety Scale (SIAS; Mattick and Clarke, 1998; Sica et al., 2007): a 19-item questionnaire measuring social interaction anxiety on a 5-point Likert scale. The Italian version of the SIAS showed strong psychometric properties, with excellent internal consistency (Sica et al., 2007). In the present study, the alpha coefficient for the SIAS was excellent (α = 0.95). The Rosenberg Self-Esteem Scale (RSES; Rosenberg, 1965; Prezza et al., 1997): a questionnaire made up of 10 items, rated on a 4-point Likert scale, assessing global self-esteem. Higher scores represent positive self-esteem. The Italian version of the RSES showed good internal consistency (Prezza et al., 1997). Internal consistency coefficient in the present sample was excellent (α = 0.93).
groups emerged (p = 0.99; Table 2). With respect to marital status and occupation, significant differences among groups emerged (p = 0.002 and p = 0.001, respectively; Table 3).
2.2. Measures All participants completed a brief schedule collecting socio-demographic information. In order to assess BDD prevalence and the presence of NWRCs, in accordance with other studies (Rief et al., 2006; Schieber et al., 2015), participants completed a self-report questionnaire including the DSM-5 criteria (APA, 2013) for BDD (four items; Table 1). The first item of the employed self-report questionnaire asked to list the area(s) of concern and participants were allowed to mention more than one NWRCs (no a priori categories of NWRCs were created). Furthermore, participants completed the following self-report measures: The Questionario sul Dismorfismo Corporeo (QDC [Questionnaire about Body Dysmorphic Disorder]; Cerea et al., 2017a): a measure made up of 40 items assessing clinical features of BDD. Items are rated on a 7-point Likert scale. The QDC evaluates the presence of typical behaviours associated with BDD, such as repetitive behaviours (e.g., mirror checking, excessive grooming, reassurance seeking), mental acts (e.g., comparing the “defective” body areas with the same body areas of other people), and avoidance behaviours related to appearance concerns. The QDC also assesses the request for cosmetic and surgical procedures and suicidal thoughts due to appearance concerns. The QDC showed strong psychometric properties, including high internal consistency (Cerea et al., 2017a). Internal consistency coefficient in the present sample was excellent (α = 0.97). The Eating Disorder Inventory-2 (EDI-2; Garner, 1991; Rizzardi et al., 1995): a 91-item questionnaire assessing psychological features and behaviours relevant in eating problems on a 6-point Likert scale. The EDI-2 subscales showed good internal consistency in a clinical sample (Rizzardi et al., 1995). For the purposes of the current study, we employed only the EDI-2 subscales assessing AN core features (drive for thinness and body dissatisfaction; see also Gupta and Johnson, 2000). In the present sample, internal consistency coefficients were α = 0.93 for the drive for thinness subscale and α = 0.90 for the body dissatisfaction subscale. The Obsessive Compulsive Inventory-42 (OCI-42; Foa et al., 1998; Sica et al., 2009): a 42-item measure assessing frequency and distress caused by OC symptoms. Each item is rated on a 5-point Likert scale. Internal consistency values of the Italian version were good (Sica et al., 2009). In the present study, only distress associated with obsessions and compulsions was taken into account since the two scales (frequency and
2.3. Procedure Patients with AN who entered the study were recruited from both inpatient and outpatient mental health clinics in Italy. The HC group was recruited through advertisements in public settings and university buildings, requesting potential volunteers for psychological studies. Before entering the study, participants were informed about the study aims and about the voluntary nature of their participation; furthermore, they were aware of the possibility of withdrawing from the study without penalty. All participants provided written informed consent; they did not receive any kind of reimbursement for their participation in the study. The study was conducted in accordance with the Declaration of Helsinki and approved by the Ethical Committee of the Psychological Sciences of the University. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. 122
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2.4. Statistical analyses
Table 4 Frequencies of non-weight-related body image concerns in patients with Anorexia Nervosa (AN).
In order to assess the presence of differences among groups on sociodemographic variables, chi-squared analyses and one-way analyses of variance (ANOVAs) were conducted. Bonferroni post-hoc comparisons were conducted to compare groups when significant differences emerged. In order to estimate the prevalence of BDD and the presence of NWRCs in patients with AN, descriptive analyses (frequencies and percentages) were performed. Finally, one-way ANOVAs were performed in order to compare groups (AN-only group vs. AN + NWRC group vs. HC group) on psychological and psychopathological features, and Bonferroni post hoc comparisons were computed when significant differences emerged. All statistical analyses were conducted using IBM SPSS statistics, version 21.
Frequencies Hair Nose Skin Teeth Height Face (shape) Body hair Breast Feet Eyes Hands Scars Shoulders Lips Moles Finger Knees Ears Back
3. Results 3.1. Presence of NWRCs and prevalence of BDD in patients with AN Among the 61 patients with AN, 39 (63.93%) reported one or more NWRCs at the questionnaire including DSM-5 criteria for BDD (Item 1; Table 1).1 The most frequently reported were: hair (41.03%), nose (30.77%), skin (30.77%), teeth (25.64%), and height (20.51%; Table 4). Among these 39 patients with NWRCs, 16 (41.03%) had probable comorbid BDD based on DSM-5 diagnostic criteria (APA, 2013) for BDD (Table 1). With respect to the overall sample, 26.23% of patients with AN had probable comorbid BDD. Patients diagnosed with comorbid BDD were primary concerned with one or more perceived defects in physical appearance unrelated to weight or body shape.
16 12 12 10 8 8 8 8 6 5 5 4 2 2 2 1 1 1 1
4. Discussion AN and BDD are characterized by body image disturbance and dissatisfaction (Rosen et al., 1995). Despite the similarities between these disorders (Grant and Phillips, 2004), few studies have explored the relation between AN and BDD. Present findings showed that 63.93% of patients with AN reported NWRCs and 26.23% of these patients screened positive for BDD. These findings are in accordance with previous studies that found high BDD prevalence in patients with AN, ranging from 9.8% (Kollei et al., 2013) to 46% (Dingemans et al., 2012), as well as high presence of NWRCs in patients with AN. To note, we observed a prevalence of BDD in the middle of the range reported by literature, and this result can be due to the adoption of DSM-5 diagnostic criteria and by methodological and sample differences. The study by Dingemans et al. (2012), for example, employed self-report questionnaires assessing BDD according to DSMIV criteria in a Dutch sample of patients with AN, whereas the studies by Kollei et al. (2013) and by Grant et al. (2002) employed both structured clinical interviews and self-report questionnaires to assess DSM-IV BDD criteria in a German and USA sample. As far as concern the most common NWRCs, we found that they were hair, nose, skin, teeth, and height. As reported in previous studies (Kollei et al., 2013; Tyler et al., 2002), the presence of concerns with hair, skin, and teeth may be partially explained by the consequences of AN core symptoms (for example, starvation, vomiting, and abuse of laxatives and diuretics); however, the presence of concerns unrelated to organ systems affected by AN, such as nose and height, may be explained by the presence of clinical and subclinical manifestation of BDD and by a severe body image disturbance not limited to weight and shape in a subgroup of our clinical sample (AN + NWRC). The evidence of a subgroup of patients characterized by clinical and subclinical manifestation of BDD is supported by the finding that the two clinical groups (AN + NWRC group and AN-only group) differed with respect to BDD symptomatology as measured by the QDC, which evaluates typical behaviours associated with BDD (Cerea et al., 2017a, b). Indeed, patients in the AN + NWRC group reported higher BDD symptoms such as repetitive behaviours, mental acts, avoidant behaviours, request of aesthetical procedures, and suicidal thoughts related to appearance than patients in the AN-only group, suggesting the presence of considerable BDD features. To note, clinical groups were equivalent with respect to weight-related measures such as BMI and EDI-2 subscales assessing the core features of AN (drive for thinness and body dissatisfaction; Gupta and Johnson, 2000). Therefore, the presence of
3.2. Psychological and psychopathological features among AN-only, AN + NWRC, and HC BDD symptoms. With respect to BDD symptoms, both the AN-only and the AN + NWRC groups scored significantly higher than the HC group on the QDC (both ps < 0.001). Moreover, the AN + NWRC group scored significantly higher than the AN-only group (p = 0.02; Table 5). EDs symptoms. The AN-only and the AN + NWRC groups scored similarly (drive for thinness p = 0.99; body dissatisfaction p = 0.07) and significantly higher than the HC group on the drive for thinness and the body dissatisfaction subscales of the EDI-2 (all ps < 0.01; Table 5). OC symptoms and general distress. With respect to OC symptoms, both the AN-only and the AN + NWRC groups scored significantly higher than the HC group on the OCI-42 (ps < 0.05). Moreover, the AN + NWRC group scored higher than the AN-only group (p = 0.04; Table 5). Concerning general distress, both the AN-only and the AN + NWRC groups scored significantly higher than the HC group on the DASS-21 (ps < 0.001), whereas no difference between the AN-only and the AN + NWRC emerged (p = 0.17; Table 5). Social anxiety and self-esteem. With respect to social anxiety, both the AN-only and the AN + NWRC groups scored significantly higher than the HC group on the SIAS (ps < 0.05). Moreover, the AN + NWRC group scored significantly higher than the AN-only group (p = 0.002; Table 5). As regards self-esteem, both the AN-only and the AN + NWRC groups scored significantly lower than the HC group on the RSES (both ps < 0.001). Moreover, the AN + NWRC group scored significantly lower than the AN-only group (p = 0.02; Table 5). 1 When NWRCs reported by patients with AN were possibly related to weight and shape concerns (e. g., face, hands, fingers, knees, etc.), clinicians trained in EDs made sure that the reported NWRCs were not related to weight and shape concerns (e.g., crooked fingers instead of fat fingers).
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Table 5 Comparisons among patients with Anorexia Nervosa (AN) and weight-related body image concerns only (AN-only group), patients with AN and non-weight-related body image concerns (AN + NWRC group) and healthy controls (HC group) on psychological and psychopathological features.
QDC EDI-2 drive for thinness EDI-2 body dissatisfaction OCI-42 total score DASS-21 total score SIAS RSES
AN-only (1) (N = 22) M (SD)
AN + NWRC (2) (N = 39) M (SD)
HC (3) (N = 61) M (SD)
F(2,119)
p
η2p
Post-hoc
140.19 (56.93) 12.90 (7.80) 12.73 (8.27) 29.95 (27.35) 25.24 (13.15) 27.24 (16.88) 23.73 (5.63)
172.54 (42.69) 13.92 (7) 17.21 (6.46) 48.23 (36.85) 31.60 (14.50) 41.47 (17.29) 19.81 (5.81)
94.64 (32.62) 3.27 (3.79) 7.42 (6.69) 18.63 (15.11) 13.27 (9.78) 16.49 (11.59) 31.70 (5.02)
39.79 46.98 23.64 11.89 27.45 21.38 59.84
<0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001
0.42 0.45 0.29 0.18 0.33 0.27 0.51
2>1>3 1=2>3 1=2>3 2>1>3 1=2>3 2>1>3 2<1<3
Note. QDC: Questionario sul Dismorfismo Corporeo; EDI-2: Eating Disorder Inventory-2; OCI-42: Obsessive Compulsive Inventory-42; DASS-21: Depression Anxiety Stress Scale-21; SIAS: Social Interaction Anxiety Scale; RSES: Rosenberg Self-Esteem Scale.
somewhat small and there was a lack of information regarding past and current comorbidity, age of the onset of AN, and duration of the illness. Furthermore, most of the patients were medicated and were receiving a treatment; therefore our findings may not be generalizable to patients with AN in the community. Despite such shortcomings, present results have crucial treatment implications. Indeed, although recent psychological treatments for AN address body image (e.g., enhanced Cognitive Behavioral Treatment; CBT-E; Fairburn et al., 2003), standard AN treatment programs focus almost exclusively on EDs pathology and demonstrated limited effectiveness in the improvement of body image (Ferrer-García and Gutiérrez-Maldonado, 2012; Rosen, 1996); indeed, the degree of clinical significant change is much greater for disturbance in eating behaviours than for body image (Davis et al., 1990; Exterkate et al., 2009; Rosen, 1996). However, the severity of body image disturbance represents one of the most important maintenance and relapse factor for AN pathology (Cash and Hrabosky, 2004; Keel et al., 2005), and changing negative appraisals related to body image is the hardest part of the recovery (Rorty et al., 1993). Indeed, since recovery in terms of weight restoration and eating pathology does not guarantee that patients will improve with respect to their body image disturbance (Rosen, 1997), relapse rates may be higher especially in patients with AN and clinical and subclinical manifestation of BDD, given the more severe body image disturbance. Of course, only longitudinal designs would allow understanding whether patients recovered from AN would be no longer characterized by the propensity for BDD; future research in this direction is warranted. Future directions should also involve the assessment of NWRCs in patients with BN and with MD, giving the overlap among these disorders. In conclusion, results from the present study should encourage practitioners assessing the presence of NWRCs in patients with AN, because they confer additional severity in terms of clinical symptomatology (Dingemans et al., 2012; Kollei et al., 2013; Grant et al., 2002); furthermore, failures in diagnosing NWRCs in patients with EDs may have important treatment implications, since standard EDs programs are usually less effective in treating body image than eating pathology (Ferrer-García and Gutiérrez-Maldonado, 2012; Perpiñá et al., 1999). In particular, treatments focused on improving body image disturbance, such as mirror retraining, virtual reality, cognitive restructuring, exposure and response prevention (Ferrer-García and GutiérrezMaldonado, 2012; Key et al., 2002; Veale and Neziroglu, 2010), may be promising for patients with AN and clinical and subclinical manifestations of BDD.
NWRCs in the AN+NWRC group seems not related to a more severe eating pathology, in contrast with results emerged in the study by Gupta and Johnson (2000); indeed, in the study by Gupta and Johnson (2000) the presence of NWRCs was associated with greater dissatisfaction with the usual weight-related indices, such as drive for thinness and body dissatisfaction. Furthermore, the AN+NWRC group resulted more impaired than the AN-only group with respect to almost all psychological and psychopathological features we assessed, with the exception of general distress. Consistently with our expectations, the AN+NWRC group reported higher levels of OC and social anxiety symptoms than the ANonly group. These results are in line with studies that showed high presence of OC symptoms in patients with BDD (Bohne et al., 2002; Gunstad and Phillips, 2003) and with studies reporting that multiple concerns about defects in physical appearance may be associated with the fear of negative evaluation by others. The fear of negative evaluation also represents the core feature of social anxiety disorder, which is frequently associated with BDD (Fang and Hofmann, 2010). Concerning self-esteem, the AN+NWRC group showed lower levels of self-esteem than the AN-only group, a result consistent with studies that found a correlation between low self-esteem and poor body esteem (Biby, 1998; Bohne et al., 2002). Lastly, the absence of differences in general distress was somewhat unexpected, given that the presence of clinical and subclinical manifestation of BDD should lead to a greater distress (Dingemans et al., 2012; Grant et al., 2002). However, both clinical groups were in treatment, and general distress may have been attenuated in the AN +NWRC group. As a whole, in accordance with the study by Rosen and Ramirez (1998), both clinical groups were more impaired than the HC group. Furthermore, the AN+NWRC group resulted more impaired than the AN-only group with respect to almost all the psychological and psychopathological features we assessed, but not in regard to AN core features (such as BMI and drive for thinness and body dissatisfaction subscales of EDI-2). Therefore, current results appear suggest that the presence of NWRCs might independently contribute to more severe psychopathology. However, it is noteworthy that we did not compare individuals with AN and comorbid BDD; rather, we focused on patients with AN and NWRCs. These findings are in accordance with previous studies that highlighted a more severe psychopathology in patients with AN and clinical and subclinical manifestation of BDD (Dingemans et al., 2012; Grant et al., 2002), thus fostering the idea that assessing clinical and subclinical manifestation of BDD in patients with AN is crucial given that, in accordance with our results, it seems to confer additional risk and severity (Dingemans et al., 2012; Grant et al., 2002). Although current findings are intriguing, several limitations characterizing the present study deserve to be mentioned. First of all, we used a self-report measure other than clinical structured interviews (which are considered the gold standard for the screening of BDD; Brohede et al. 2015) to assess BDD; therefore, data on BDD prevalence should be interpreted with caution. Secondly, the sample size was
Declaration of interest None. References American Psychiatric Association, 2013. Diagnostic and Statistical Manual of Mental Disorders: DSM-5. American Psychiatric Association, Washington, DC. Biby, E.L., 1998. The relationship between body dysmorphic disorder and depression,
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Non-weight-related body image concerns and Body Dysmorphic Disorder prevalence in patients with Anorexia Nervosa
T
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Silvia Cereaa, , Gioia Bottesia, Jessica R. Grishamb, Marta Ghisia a b
Department of General Psychology, University of Padova, Padova, Italy School of Psychology, University of New South Wales, Sydney, Australia
A R T I C LE I N FO
A B S T R A C T
Keywords: Anorexia Nervosa Body Dysmorphic Disorder Psychological features Psychopathological features
Patients with Anorexia Nervosa (AN) and patients with Body Dysmorphic Disorder (BDD) are both characterized by body image disturbance and dissatisfaction; furthermore, these disorders share clinical features and frequently co-occur. However, few studies have explored the relation between AN and BDD. Therefore, the first aim of the study was assessing the prevalence of BDD and presence of non-weight-related body image concerns in patients with AN. Second, we were interested in comparing patients with AN and non-weight-related body image concerns, patients with weight-related body image concerns only, and a healthy control group with respect to several psychological and psychopathological features. Sixty-one female patients with AN were divided in two subgroups: 39 with non-weight-related body image concerns and 22 with weight-related body image concerns only. Sixteen (26.23%) patients with AN had probable comorbid BDD. Moreover, patients with AN and nonweight-related body image concerns reported, overall, greater psychopathology than patients with AN and weight-related body image concerns only, with the exception of AN core features and general distress. In conclusion, patients with AN and non-weight-related body image concerns showed a more severe body image disturbance unrelated to a more severe eating disorder pathology.
1. Introduction Body Dysmorphic Disorder (BDD) is a psychiatric condition characterized by concerns regarding one or more perceived defects in physical appearance that are not observable to others (American Psychiatric Association, 2013). Appearance concern is often focused on skin, hair, and nose (Phillips and Diaz, 1997; Phillips et al., 1993; Veale et al., 1996); however, it may involve any body areas (Veale, 2000) and individuals with BDD may be simultaneously concerned with multiple body parts (Phillips et al., 2005). Because the essential pathology of BDD is a disturbance in body image (Rosen and Ramirez, 1998), it has been suggested that BDD might be better clustered under an encompassing ‘body image disorder’ category, along with Eating Disorders (EDs; Mitchison et al., 2013; Phillipou et al., 2015, 2017); however, data from a recent study did not support this cluster in male and female adolescents (Schneider et al., 2018). Both BDD and EDs are severe body image disorders (Rosen et al., 1995) characterized by body image disturbance and dissatisfaction. Moreover, BDD and EDs share clinical features (Grant and Phillips, 2004): both disorders are characterized by dissatisfaction about appearance and by an overemphasis on appearance in the
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Corresponding author. E-mail address: [email protected] (S. Cerea).
https://doi.org/10.1016/j.psychres.2018.05.068 Received 27 November 2017; Received in revised form 22 May 2018; Accepted 26 May 2018 Available online 31 May 2018 0165-1781/ © 2018 Elsevier B.V. All rights reserved.
evaluation of self-worth (Rosen and Ramirez, 1998). Furthermore, both disorders are characterized by similar onset and course, cognitive characteristics (such as information processing deficits), and personality traits, such as high levels of perfectionism and low self-esteem (Hartmann et al., 2013). Due to this considerable overlap, distinguishing between BDD and EDs is sometimes challenging (Dingemans et al., 2012). However, people with EDs focus primarily on body weight and shape, whereas people with BDD focus on specific body parts (Phillips et al., 1995); nevertheless, high rates of dissatisfaction with body areas unrelated to weight or shape (non-weightrelated body image concerns, NWRCs) can characterize patients with EDs (Kollei et al., 2013), and concerns related to body shape and weight can characterize patients with BDD (Ruffolo et al., 2006) and Muscle Dysmorphia (MD; Pope et al., 1997). MD is subtype of BDD characterized by the preoccupation with the idea that one's body is not sufficiently lean and muscular (APA, 2013; Pope et al., 1997; Pope et al., 2000); the core feature of MD resembles those of eating disorders, particularly anorexia nervosa (AN), in that a disturbed perception of body image is present (Phillipou et al., 2015). Furthermore, both disorders are characterized by compulsive exercise and rigid diet (Olivardia et al., 2000; Nieuwoudt et al., 2015).
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Table 1 Diagnostic criteria for BDD (DSM-5; American Psychiatric Association, 2013). Description of DSM-5 criteria
Item
A. Preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others.
1. Are you concerned about the presence of one or more perceived defects in your physical appearance that are not observable or appear slight to others? If yes, please list the area(s) of concern and the degree of dissatisfaction with each area(s) 2. Do you perform repetitive behaviours (e.g. mirror checking, skin picking, reassurance seeking) or mental acts (e.g. comparing appearance with that of others) in response to the appearance concerns?
B. At some point during the course of the disorder, the individual has performed repetitive behaviours (e.g., mirror checking, excessive grooming, skin picking, reassurance seeking) or mental acts (e.g., comparing his or her appearance with that of others) in response to the appearance concerns C. The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
3. Does the preoccupation about your physical defect(s) cause you significant distress or impairment in your everyday life? Does the preoccupation about your physical defect(s) caused you significant impairment in your social activities? If yes: Please describe how. Does the preoccupation about your physical defect(s) caused you significant problems with school, work, or other activities? If yes: Please describe how. Are there things you avoid because of the preoccupation about your physical defect (s)? If yes: Please describe how. 4. Is your weight or shape the primary cause of your appearance concerns?
D. The appearance preoccupation is not better explained by concerns with body fat or weight in an individual whose symptoms meet diagnostic criteria for an eating disorder.
Note. A positive screen for BDD is obtained if participants report positive answers to questions one, two and three. Moreover, a negative answer to question number four is required.
presence of NWRCs in patients with AN in accordance with DSM-5 (APA, 2013) diagnostic criteria for BDD. We chose to restrict our investigation to patients with AN in light of the similarities between AN (rather than BN) and BDD in terms of severity, onset and course, and clinical features (Hartmann et al., 2013). It represents the first study aimed at comparing patients with AN and NWRCs with patients with AN and weight-related body image concerns (WRCs) only with respect to BDD symptoms, core features of EDs, obsessive-compulsive (OC) symptoms, general distress, social anxiety symptoms, and self-esteem. Furthermore, both clinical groups were compared with a healthy control (HC) group. Similar to previous studies (Dingemans et al., 2012; Grant et al., 2002; Kollei et al., 2013), we expected high BDD prevalence and high presence of NWRCs in patients with AN (Dingemans et al., 2012; Grant et al., 2002). Furthermore, we expected that patients with AN and NWRCs would show higher levels of psychological and psychopathological symptoms and lower self-esteem than patients with AN and WRCs only and the HC group.
The current hierarchical organization of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5; APA, 2013) stipulates that a diagnosis of BDD cannot be provided if appearance concerns are better explained by concerns with body fat or weight in an individual whose symptoms meet diagnostic criteria for EDs (APA, 2013); this frequently results in not diagnosing BDD when patients fulfill the criteria for EDs (Dingemans et al., 2012). So far, only a few studies have investigated the prevalence of BDD and the presence of NWRCs in patients with EDs, and found high comorbidity of BDD and EDs, as well as high presence of NWRCs (Dingemans et al., 2012; Grant et al., 2002; Kollei et al., 2013; Ruffolo et al., 2006). However, the majority of these studies share similar shortcomings. For example, the study by Grant et al. (2002), conducted on 41 inpatients with Anorexia Nervosa (AN), did not include a control group and did not investigate the possibility of a more severe EDs pathology in patients with AN and comorbid BDD. Authors found that patients with AN and comorbid BDD were dissatisfied with their nose, skin, hair, chin, lips, and eyes, and that they were three times more likely to have attempted suicide secondary to appearance concerns than those without comorbid BDD (Grant et al., 2002). The study by Kollei et al. (2013) found that 14.3% of patients with Bulimia Nervosa (BN) and 9.8% of patients with AN met criteria for BDD; the most commonly reported areas of concern were skin, arms, eyebrows, and nose. However, authors did not include a control group and participants were only inpatients with EDs. The study by Dingemans et al. (2012) found that 45% of patients with EDs (n = 158) probably suffered from BDD, and that inpatients with comorbid BDD referred earlier onset of AN, greater severity of EDs pathology, and general symptomatology than those without comorbid BDD. However, control group was lacking and the presence of NWRCs was not explored. Despite the above-mentioned limitations, these studies underlined the importance of assessing the prevalence of BDD and the presence of NWRCs (which can be conceptualized as subclinical manifestation of BDD) in patients with EDs (Dingemans et al., 2012; Kollei et al., 2013; Grant et al., 2002). Indeed, the presence of NWRCs in patients with EDs confers additional severity in terms of clinical symptomatology (Dingemans et al., 2012; Kollei et al., 2013; Grant et al., 2002). To note, failures in diagnosing BDD and NWRCs in patients with EDs may have important treatment implications, since standard EDs programs focus almost exclusively on eating pathology and are usually less effective in treating body image compared to eating pathology (Ferrer-García and Gutiérrez-Maldonado, 2012; Perpiñá et al., 1999). The current study aimed at assessing the prevalence of BDD and the
2. Methods 2.1. Participants Sixty-one female patients suffering from AN entered the study. Diagnostic status was ascertained using the Structured Clinical Interview for Axis I Disorders, Patient Edition (SCID-I/P; First et al., 2002). Inclusion criteria for all participants were meeting criteria for current AN and being aged at least 18 years old. Exclusion criteria were the existence of severe neurological diseases, current or past psychotic disorders, and mental retardation. All patients were in treatment (57.4% inpatient and 42.6% outpatient/day hospital) and most of them (68.85%) were medicated: fluoxetine and sertraline were the most represented medications. Patients with AN were divided, according to the presence of NWRCs (Table 1), in two subgroups: patients with WRCs only (AN-only; N = 22) and patients with NWRCs (AN + NWRC; N = 39). An additional group of 61 HCs was recruited. None of the HCs met diagnostic criteria for any current psychiatric disorder and none were taking any psychiatric medications. Groups were equivalent with respect to age and years of education (Table 2), whereas significant differences on Body Mass Index (BMI) emerged: Bonferroni post hoc comparisons revealed that the BMI of both clinical groups was lower than the BMI of the HC group (p < 0.001), whereas no differences between clinical 121
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Table 2 Comparisons among patients with Anorexia Nervosa (AN) and weight-related body image concerns only (AN-only group), patients with AN and non-weight-related body image concerns (AN + NWRC group), and healthy controls (HC group) on age, years of education and Body Mass Index (BMI).
Age Years of education BMI
AN-only (1) (N = 22) M (SD)
AN + NWRC (2) (N = 39) M (SD)
HC (3) (N = 61) M (SD)
F
28 (10.12) 12.73 (3.64) 16.68 (2.38)
24.56 (8.81) 12.84 (2.54) 16.32 (2.41)
25.97 (9.34) 12.98 (2.48) 22.02 (3.12)
0.96 0.08 61.19
(2,119)
p
η2p
Post-hoc
0.39 0.92 <0.001
– – 0.51
– – 1=2<3
Table 3 Frequencies of occupation and marital status of patients with Anorexia Nervosa (AN) and weight-related body image concerns only (AN-only group), patients with AN and non-weight-related body image concerns (AN + NWRC group) and healthy controls (HC group). Occupation
AN-only (N = 22)
AN + NWRC (N = 39)
HC (N = 61)
Marital status
AN-only (N = 22)
AN + NWRC (N = 39)
HC (N = 61)
Student Full time employed Part time employed Unemployed Other
9 2 0 8 2
21 6 4 5 3
37 9 5 0 7
Single In a relationship Married
14 3 5
27 7 4
20 29 12
distress) have been demonstrated to yield redundant information (e.g., Foa et al., 2002). For the purpose of the current study we focused only on the total score of the questionnaire. In the present study, the alpha coefficient for the total OCI distress was α = 0.96. The Depression Anxiety Stress Scale-21 (DASS-21; Lovibond and Lovibond, 1995; Bottesi et al., 2015): a 21-item measure assessing depression, anxiety, and stress on a 4-point Likert scale. Three subscale scores as well as a total score can be computed (Bottesi et al., 2015). The Italian DASS-21 showed adequate reliability. Given that findings on the Italian version suggested that use of the total score, measuring a “general distress” factor, could be more appropriate than calculating the three subscale scores separately (Bottesi et al., 2015), for the purpose of the presence research we focused only on the total score of the questionnaire. In the present study, the alpha coefficient for the total DASS-21 was excellent (α = 0.95). The Social Interaction Anxiety Scale (SIAS; Mattick and Clarke, 1998; Sica et al., 2007): a 19-item questionnaire measuring social interaction anxiety on a 5-point Likert scale. The Italian version of the SIAS showed strong psychometric properties, with excellent internal consistency (Sica et al., 2007). In the present study, the alpha coefficient for the SIAS was excellent (α = 0.95). The Rosenberg Self-Esteem Scale (RSES; Rosenberg, 1965; Prezza et al., 1997): a questionnaire made up of 10 items, rated on a 4-point Likert scale, assessing global self-esteem. Higher scores represent positive self-esteem. The Italian version of the RSES showed good internal consistency (Prezza et al., 1997). Internal consistency coefficient in the present sample was excellent (α = 0.93).
groups emerged (p = 0.99; Table 2). With respect to marital status and occupation, significant differences among groups emerged (p = 0.002 and p = 0.001, respectively; Table 3).
2.2. Measures All participants completed a brief schedule collecting socio-demographic information. In order to assess BDD prevalence and the presence of NWRCs, in accordance with other studies (Rief et al., 2006; Schieber et al., 2015), participants completed a self-report questionnaire including the DSM-5 criteria (APA, 2013) for BDD (four items; Table 1). The first item of the employed self-report questionnaire asked to list the area(s) of concern and participants were allowed to mention more than one NWRCs (no a priori categories of NWRCs were created). Furthermore, participants completed the following self-report measures: The Questionario sul Dismorfismo Corporeo (QDC [Questionnaire about Body Dysmorphic Disorder]; Cerea et al., 2017a): a measure made up of 40 items assessing clinical features of BDD. Items are rated on a 7-point Likert scale. The QDC evaluates the presence of typical behaviours associated with BDD, such as repetitive behaviours (e.g., mirror checking, excessive grooming, reassurance seeking), mental acts (e.g., comparing the “defective” body areas with the same body areas of other people), and avoidance behaviours related to appearance concerns. The QDC also assesses the request for cosmetic and surgical procedures and suicidal thoughts due to appearance concerns. The QDC showed strong psychometric properties, including high internal consistency (Cerea et al., 2017a). Internal consistency coefficient in the present sample was excellent (α = 0.97). The Eating Disorder Inventory-2 (EDI-2; Garner, 1991; Rizzardi et al., 1995): a 91-item questionnaire assessing psychological features and behaviours relevant in eating problems on a 6-point Likert scale. The EDI-2 subscales showed good internal consistency in a clinical sample (Rizzardi et al., 1995). For the purposes of the current study, we employed only the EDI-2 subscales assessing AN core features (drive for thinness and body dissatisfaction; see also Gupta and Johnson, 2000). In the present sample, internal consistency coefficients were α = 0.93 for the drive for thinness subscale and α = 0.90 for the body dissatisfaction subscale. The Obsessive Compulsive Inventory-42 (OCI-42; Foa et al., 1998; Sica et al., 2009): a 42-item measure assessing frequency and distress caused by OC symptoms. Each item is rated on a 5-point Likert scale. Internal consistency values of the Italian version were good (Sica et al., 2009). In the present study, only distress associated with obsessions and compulsions was taken into account since the two scales (frequency and
2.3. Procedure Patients with AN who entered the study were recruited from both inpatient and outpatient mental health clinics in Italy. The HC group was recruited through advertisements in public settings and university buildings, requesting potential volunteers for psychological studies. Before entering the study, participants were informed about the study aims and about the voluntary nature of their participation; furthermore, they were aware of the possibility of withdrawing from the study without penalty. All participants provided written informed consent; they did not receive any kind of reimbursement for their participation in the study. The study was conducted in accordance with the Declaration of Helsinki and approved by the Ethical Committee of the Psychological Sciences of the University. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. 122
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2.4. Statistical analyses
Table 4 Frequencies of non-weight-related body image concerns in patients with Anorexia Nervosa (AN).
In order to assess the presence of differences among groups on sociodemographic variables, chi-squared analyses and one-way analyses of variance (ANOVAs) were conducted. Bonferroni post-hoc comparisons were conducted to compare groups when significant differences emerged. In order to estimate the prevalence of BDD and the presence of NWRCs in patients with AN, descriptive analyses (frequencies and percentages) were performed. Finally, one-way ANOVAs were performed in order to compare groups (AN-only group vs. AN + NWRC group vs. HC group) on psychological and psychopathological features, and Bonferroni post hoc comparisons were computed when significant differences emerged. All statistical analyses were conducted using IBM SPSS statistics, version 21.
Frequencies Hair Nose Skin Teeth Height Face (shape) Body hair Breast Feet Eyes Hands Scars Shoulders Lips Moles Finger Knees Ears Back
3. Results 3.1. Presence of NWRCs and prevalence of BDD in patients with AN Among the 61 patients with AN, 39 (63.93%) reported one or more NWRCs at the questionnaire including DSM-5 criteria for BDD (Item 1; Table 1).1 The most frequently reported were: hair (41.03%), nose (30.77%), skin (30.77%), teeth (25.64%), and height (20.51%; Table 4). Among these 39 patients with NWRCs, 16 (41.03%) had probable comorbid BDD based on DSM-5 diagnostic criteria (APA, 2013) for BDD (Table 1). With respect to the overall sample, 26.23% of patients with AN had probable comorbid BDD. Patients diagnosed with comorbid BDD were primary concerned with one or more perceived defects in physical appearance unrelated to weight or body shape.
16 12 12 10 8 8 8 8 6 5 5 4 2 2 2 1 1 1 1
4. Discussion AN and BDD are characterized by body image disturbance and dissatisfaction (Rosen et al., 1995). Despite the similarities between these disorders (Grant and Phillips, 2004), few studies have explored the relation between AN and BDD. Present findings showed that 63.93% of patients with AN reported NWRCs and 26.23% of these patients screened positive for BDD. These findings are in accordance with previous studies that found high BDD prevalence in patients with AN, ranging from 9.8% (Kollei et al., 2013) to 46% (Dingemans et al., 2012), as well as high presence of NWRCs in patients with AN. To note, we observed a prevalence of BDD in the middle of the range reported by literature, and this result can be due to the adoption of DSM-5 diagnostic criteria and by methodological and sample differences. The study by Dingemans et al. (2012), for example, employed self-report questionnaires assessing BDD according to DSMIV criteria in a Dutch sample of patients with AN, whereas the studies by Kollei et al. (2013) and by Grant et al. (2002) employed both structured clinical interviews and self-report questionnaires to assess DSM-IV BDD criteria in a German and USA sample. As far as concern the most common NWRCs, we found that they were hair, nose, skin, teeth, and height. As reported in previous studies (Kollei et al., 2013; Tyler et al., 2002), the presence of concerns with hair, skin, and teeth may be partially explained by the consequences of AN core symptoms (for example, starvation, vomiting, and abuse of laxatives and diuretics); however, the presence of concerns unrelated to organ systems affected by AN, such as nose and height, may be explained by the presence of clinical and subclinical manifestation of BDD and by a severe body image disturbance not limited to weight and shape in a subgroup of our clinical sample (AN + NWRC). The evidence of a subgroup of patients characterized by clinical and subclinical manifestation of BDD is supported by the finding that the two clinical groups (AN + NWRC group and AN-only group) differed with respect to BDD symptomatology as measured by the QDC, which evaluates typical behaviours associated with BDD (Cerea et al., 2017a, b). Indeed, patients in the AN + NWRC group reported higher BDD symptoms such as repetitive behaviours, mental acts, avoidant behaviours, request of aesthetical procedures, and suicidal thoughts related to appearance than patients in the AN-only group, suggesting the presence of considerable BDD features. To note, clinical groups were equivalent with respect to weight-related measures such as BMI and EDI-2 subscales assessing the core features of AN (drive for thinness and body dissatisfaction; Gupta and Johnson, 2000). Therefore, the presence of
3.2. Psychological and psychopathological features among AN-only, AN + NWRC, and HC BDD symptoms. With respect to BDD symptoms, both the AN-only and the AN + NWRC groups scored significantly higher than the HC group on the QDC (both ps < 0.001). Moreover, the AN + NWRC group scored significantly higher than the AN-only group (p = 0.02; Table 5). EDs symptoms. The AN-only and the AN + NWRC groups scored similarly (drive for thinness p = 0.99; body dissatisfaction p = 0.07) and significantly higher than the HC group on the drive for thinness and the body dissatisfaction subscales of the EDI-2 (all ps < 0.01; Table 5). OC symptoms and general distress. With respect to OC symptoms, both the AN-only and the AN + NWRC groups scored significantly higher than the HC group on the OCI-42 (ps < 0.05). Moreover, the AN + NWRC group scored higher than the AN-only group (p = 0.04; Table 5). Concerning general distress, both the AN-only and the AN + NWRC groups scored significantly higher than the HC group on the DASS-21 (ps < 0.001), whereas no difference between the AN-only and the AN + NWRC emerged (p = 0.17; Table 5). Social anxiety and self-esteem. With respect to social anxiety, both the AN-only and the AN + NWRC groups scored significantly higher than the HC group on the SIAS (ps < 0.05). Moreover, the AN + NWRC group scored significantly higher than the AN-only group (p = 0.002; Table 5). As regards self-esteem, both the AN-only and the AN + NWRC groups scored significantly lower than the HC group on the RSES (both ps < 0.001). Moreover, the AN + NWRC group scored significantly lower than the AN-only group (p = 0.02; Table 5). 1 When NWRCs reported by patients with AN were possibly related to weight and shape concerns (e. g., face, hands, fingers, knees, etc.), clinicians trained in EDs made sure that the reported NWRCs were not related to weight and shape concerns (e.g., crooked fingers instead of fat fingers).
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Table 5 Comparisons among patients with Anorexia Nervosa (AN) and weight-related body image concerns only (AN-only group), patients with AN and non-weight-related body image concerns (AN + NWRC group) and healthy controls (HC group) on psychological and psychopathological features.
QDC EDI-2 drive for thinness EDI-2 body dissatisfaction OCI-42 total score DASS-21 total score SIAS RSES
AN-only (1) (N = 22) M (SD)
AN + NWRC (2) (N = 39) M (SD)
HC (3) (N = 61) M (SD)
F(2,119)
p
η2p
Post-hoc
140.19 (56.93) 12.90 (7.80) 12.73 (8.27) 29.95 (27.35) 25.24 (13.15) 27.24 (16.88) 23.73 (5.63)
172.54 (42.69) 13.92 (7) 17.21 (6.46) 48.23 (36.85) 31.60 (14.50) 41.47 (17.29) 19.81 (5.81)
94.64 (32.62) 3.27 (3.79) 7.42 (6.69) 18.63 (15.11) 13.27 (9.78) 16.49 (11.59) 31.70 (5.02)
39.79 46.98 23.64 11.89 27.45 21.38 59.84
<0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001
0.42 0.45 0.29 0.18 0.33 0.27 0.51
2>1>3 1=2>3 1=2>3 2>1>3 1=2>3 2>1>3 2<1<3
Note. QDC: Questionario sul Dismorfismo Corporeo; EDI-2: Eating Disorder Inventory-2; OCI-42: Obsessive Compulsive Inventory-42; DASS-21: Depression Anxiety Stress Scale-21; SIAS: Social Interaction Anxiety Scale; RSES: Rosenberg Self-Esteem Scale.
somewhat small and there was a lack of information regarding past and current comorbidity, age of the onset of AN, and duration of the illness. Furthermore, most of the patients were medicated and were receiving a treatment; therefore our findings may not be generalizable to patients with AN in the community. Despite such shortcomings, present results have crucial treatment implications. Indeed, although recent psychological treatments for AN address body image (e.g., enhanced Cognitive Behavioral Treatment; CBT-E; Fairburn et al., 2003), standard AN treatment programs focus almost exclusively on EDs pathology and demonstrated limited effectiveness in the improvement of body image (Ferrer-García and Gutiérrez-Maldonado, 2012; Rosen, 1996); indeed, the degree of clinical significant change is much greater for disturbance in eating behaviours than for body image (Davis et al., 1990; Exterkate et al., 2009; Rosen, 1996). However, the severity of body image disturbance represents one of the most important maintenance and relapse factor for AN pathology (Cash and Hrabosky, 2004; Keel et al., 2005), and changing negative appraisals related to body image is the hardest part of the recovery (Rorty et al., 1993). Indeed, since recovery in terms of weight restoration and eating pathology does not guarantee that patients will improve with respect to their body image disturbance (Rosen, 1997), relapse rates may be higher especially in patients with AN and clinical and subclinical manifestation of BDD, given the more severe body image disturbance. Of course, only longitudinal designs would allow understanding whether patients recovered from AN would be no longer characterized by the propensity for BDD; future research in this direction is warranted. Future directions should also involve the assessment of NWRCs in patients with BN and with MD, giving the overlap among these disorders. In conclusion, results from the present study should encourage practitioners assessing the presence of NWRCs in patients with AN, because they confer additional severity in terms of clinical symptomatology (Dingemans et al., 2012; Kollei et al., 2013; Grant et al., 2002); furthermore, failures in diagnosing NWRCs in patients with EDs may have important treatment implications, since standard EDs programs are usually less effective in treating body image than eating pathology (Ferrer-García and Gutiérrez-Maldonado, 2012; Perpiñá et al., 1999). In particular, treatments focused on improving body image disturbance, such as mirror retraining, virtual reality, cognitive restructuring, exposure and response prevention (Ferrer-García and GutiérrezMaldonado, 2012; Key et al., 2002; Veale and Neziroglu, 2010), may be promising for patients with AN and clinical and subclinical manifestations of BDD.
NWRCs in the AN+NWRC group seems not related to a more severe eating pathology, in contrast with results emerged in the study by Gupta and Johnson (2000); indeed, in the study by Gupta and Johnson (2000) the presence of NWRCs was associated with greater dissatisfaction with the usual weight-related indices, such as drive for thinness and body dissatisfaction. Furthermore, the AN+NWRC group resulted more impaired than the AN-only group with respect to almost all psychological and psychopathological features we assessed, with the exception of general distress. Consistently with our expectations, the AN+NWRC group reported higher levels of OC and social anxiety symptoms than the ANonly group. These results are in line with studies that showed high presence of OC symptoms in patients with BDD (Bohne et al., 2002; Gunstad and Phillips, 2003) and with studies reporting that multiple concerns about defects in physical appearance may be associated with the fear of negative evaluation by others. The fear of negative evaluation also represents the core feature of social anxiety disorder, which is frequently associated with BDD (Fang and Hofmann, 2010). Concerning self-esteem, the AN+NWRC group showed lower levels of self-esteem than the AN-only group, a result consistent with studies that found a correlation between low self-esteem and poor body esteem (Biby, 1998; Bohne et al., 2002). Lastly, the absence of differences in general distress was somewhat unexpected, given that the presence of clinical and subclinical manifestation of BDD should lead to a greater distress (Dingemans et al., 2012; Grant et al., 2002). However, both clinical groups were in treatment, and general distress may have been attenuated in the AN +NWRC group. As a whole, in accordance with the study by Rosen and Ramirez (1998), both clinical groups were more impaired than the HC group. Furthermore, the AN+NWRC group resulted more impaired than the AN-only group with respect to almost all the psychological and psychopathological features we assessed, but not in regard to AN core features (such as BMI and drive for thinness and body dissatisfaction subscales of EDI-2). Therefore, current results appear suggest that the presence of NWRCs might independently contribute to more severe psychopathology. However, it is noteworthy that we did not compare individuals with AN and comorbid BDD; rather, we focused on patients with AN and NWRCs. These findings are in accordance with previous studies that highlighted a more severe psychopathology in patients with AN and clinical and subclinical manifestation of BDD (Dingemans et al., 2012; Grant et al., 2002), thus fostering the idea that assessing clinical and subclinical manifestation of BDD in patients with AN is crucial given that, in accordance with our results, it seems to confer additional risk and severity (Dingemans et al., 2012; Grant et al., 2002). Although current findings are intriguing, several limitations characterizing the present study deserve to be mentioned. First of all, we used a self-report measure other than clinical structured interviews (which are considered the gold standard for the screening of BDD; Brohede et al. 2015) to assess BDD; therefore, data on BDD prevalence should be interpreted with caution. Secondly, the sample size was
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