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Superior face recognition in Body Dysmorphic Disorder
Journal of Obsessive-Compulsive and Related Disorders 1 (2012) 175–179
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Superior face recognition in Body Dysmorphic Disorder Kiri Jefferies a,b,n, Keith R. Laws a, Naomi A. Fineberg b a b
University of Hertfordshire School of Psychology, College Lane, Hatfield, Hertfordshire AL10 9AB, UK National OCD Specialist Service, Herts Partnership NHS Foundation Trust, Queen Elizabeth II Hospital, Welwyn Garden City, Herts, UK
a r t i c l e i n f o
abstract
Article history: Received 27 September 2011 Received in revised form 12 March 2012 Accepted 14 March 2012 Available online 4 April 2012
Introduction: Individuals with Body Dysmorphic Disorder (BDD) may have a propensity for viewing faces differently from healthy controls. In an attempt to explore these processing changes in more detail, we investigate face processing in BDD using two facial recognition tasks; one testing the recognition of facial characteristics, the other testing the recognition of facial expressions of emotion. Method: Participants with BDD (n ¼ 12) and healthy controls (n ¼ 16) were tested for inverted face recognition using the Famous Faces Task (FFT) and the Facial Expression of Emotions Stimulus and Test emotion recognition task (FEEST). The groups were matched for age, IQ and education. Results: Participants with BDD showed a significant ability to correctly recognise inverted famous faces compared to well-matched controls. In contrast, participants with BDD showed a specific deficit in recognising fearful facial emotions. BDD participants excel over controls at performing the FFT. Conclusions: These findings may represent a cognitive marker for BDD. The specific deficit within the BDD group for recognising fearful expressions may be another feature of the disorder and may implicate abnormal processing of negatively valenced emotional material. The specificity of these findings for BDD merit further investigation using other clinical groups and a larger sample size. & 2012 Elsevier Ltd All rights reserved.
Keywords: Body Dysmorphic Disorder Obsessive compulsive disorder Face Anxiety
1. Introduction Body Dysmorphic Disorder (BDD), the obsessive preoccupation with perceived defects in appearance, has been estimated to affect 1–2% of the population (Rief, Buhlmann, Wilhelm, Borkenhagen, & Br¨ahler, 2006). Individuals with BDD are concerned they have a bodily imperfection that they consider unsightly, and they fear subsequent negative evaluation by others. In some cases, they exaggerate a trivial flaw; in other cases they are troubled by an imaginary defect. The symptoms of BDD are associated with considerable distress, and in one study (Eisen, Phillips, Coles, & Rasmussen, 2004), as many as 39% of BDD individuals appeared to lack insight into their fixed, false beliefs. Moreover, in an attempt to minimise or hide the defect, or to disconfirm their fears, individuals with BDD engage in time-consuming compulsive behaviours, such as mirror checking (Veale, 2001), applying makeup (camouflaging) and seeking reassurance about their appearance (Goodman et al., 1989). In an attempt to reduce distress, they often engage in social avoidance.
n Corresponding author at: University of Hertfordshire School of Psychology, College Lane, Hatfield, Hertfordshire AL10 9AB, UK. Tel.: þ44 7736 048 630; fax: þ 44 1707 365 169. E-mail addresses: [email protected] (K. Jefferies), [email protected] (K.R. Laws), [email protected] (N.A. Fineberg).
2211-3649/$ - see front matter & 2012 Elsevier Ltd All rights reserved. http://dx.doi.org/10.1016/j.jocrd.2012.03.002
The most common preoccupation in BDD patients is with facial appearance (Phillips, 1996), frequently focusing on specific facial features with which they are unhappy, but also checking the appearance and facial features of others to make comparisons with their own. Grocholewski, Kliem, and Heinrichs (in press) examined eye tracking in individuals with BDD, social anxiety and healthy controls when looking at their own and others’ faces. Only patients with BDD showed heightened fixation to an imagined defect in their own face, but also to corresponding regions in unfamiliar faces, supporting the notion of a specific attentional bias in BDD. Imaging studies point to greater left hemisphere activity thought indicative of greater encoding and analysis of detail as opposed to more holistic and configural processing of faces in BDD (Feusner, Townsend, Bystritsky, & Bookheimer, 2007). Imaging has also documented visual processing and fronto-striatal differences when individuals with BDD are viewing their own face (Feusner et al., 2010c) and that the brain activity in these systems correlates with symptom severity. Obviously, facial expressions are a key way through which we express positive or negative thoughts, feelings and attitudes. Given the fear of negative evaluation and the frequent ideas of reference (e.g., that others are staring at them), individuals with BDD might be especially sensitive to facial expressions. For example, they might misinterpret a neutral facial expression as negative (Buhlmann, McNally, Etcoff, Tuschen-Caffier, & Wilhelm, 2004;
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Buhlmann, Etcoff, & Wilhelm, 2006). Research examining aspects of facial emotion recognition suggests that compared with controls, individuals with BDD have poorer recognition of negatively valenced facial emotions, especially when viewed from their own ‘perspective’ (Williams, Watts, MacLeod, & Mathews, 1997; Buhlmann, McNally, Wilhelm, & Florin, 2002). According to Buhlmann et al. (2004), compared with healthy controls and patients with obsessive-compulsive disorder (OCD), those with BDD show a bias toward misinterpreting facial expressions as angry, including neutral but also disgusted expressions. A later study by Buhlmann et al. (2006) found that individuals with BDD misinterpreted expressions as angry in ‘‘self-referent’’ situations (imagining themselves in a situation) but not in ‘‘other-referent’’ situations. Buhlmann, Gleiss, Rupf, Zschenderlein, and Kathmann (2011) also found that compared to healthy controls and individuals with dermatological conditions, BDD patients were more likely to misinterpret neutral expressions as negative emotions. These findings suggest that individuals with BDD believe other people share their own negative appraisal of their appearance; which might serve to maintain the disorder. In a thematic analysis, which included a qualitative analysis of conversation guided by self-portraits, Silver, Reavey, and Fineberg (2010) found a tendency for individuals with BDD to focus on facial detail rather than view the face as a whole. The most common theme was a heightened threat perception characterised by the participants being very sensitive to comments made by others that they interpreted as being critical of themselves. In addition, the majority of the participants expressed a wish for facial symmetry, possibly indicating a tendency to view the face in separate parts as opposed to as a whole. Consistent with this ¨ finding, Stangier, Adam-Schwebe, Muller, and Wolter (2008) reported that BDD patients were significantly more accurate than controls in detecting changes in photographs that are manipulated with regard to facial features (hair loss, scars size of the nose, etc.). A recently published study (Feusner et al., 2010b) investigated inverted face identification in individuals with BDD compared with healthy controls. Participants viewed upright photographs of unfamiliar faces (judged to be of average attractiveness) for 5000 ms, 3000 ms or 500 ms and were then asked to select from two photographs the picture that was the same as the target face. Compared with the control group, the BDD group was significantly faster when given 5000 ms; however, no group difference emerged for shorter viewing times. No evidence of a significant accuracy difference emerged between the two groups for any trial. The authors suggested that the extra time taken to view the image may allow a partial ‘decomposition’ of the face into constituent parts that is processed particularly well by BDD sufferers. Recognition of emotional expressions was also recently studied by Feusner, Bystritsky, Hellemann, and Bookheimer, (2010a) in which individuals with and without BDD were asked to match identities of faces to their emotional expressions. Participants also completed a control task matching ovals and circles instead of faces. The BDD group made twice as many errors as control subjects when matching faces to their emotional expressions, irrespective of the nature of the expression, but did not differ on the control task. This result suggests a rather general impairment in the processing of facial expressions. A high incidence of comorbidity exists within the BDD population and most commonly in the form of depression and social anxiety disorder (SAD: Phillips, & Diaz, 1997; NezirogluMcKay, Todaro, & Yaryura-Tobias, 1996; Veale et al., 1996). SAD is a disorder characterised by intense avoidance of social situations owing to the fear of negative evaluation by others. In this respect, SAD may be difficult to distinguish from BDD in the clinical scenario. Patients with SAD also show an abnormality in recognising facial expressions. Moriya and Tanno (2011) conducted a
task in which individuals with SAD with high anxiety, low anxiety and healthy controls were asked to view neutral and angry faces. Individuals with high anxiety had difficulty disengaging with the angry stimulus, suggesting a bias for and misinterpretation of threatening faces. Other research using dynamic stimuli (pictures of faces slowly morphing from neutral to a full expression of happiness, sadness, fear, etc.) suggests that individuals with SAD misinterpret threatening faces and show an inability to disengage from the image when they have to identify them quickly and efficiently. The present study examined facial emotion recognition and familiar face recognition for both upright and inverted faces in individuals with and without BDD. The research reviewed above leads to the hypothesis that individuals with BDD would show a bias toward misinterpreting facial expressions depicting negative emotions, and a tendency toward more effective identification of facial characteristics than controls that would become more evident with increasing difficulty i.e. when the image is inverted.
2. Method 2.1. Participants Twenty-eight individuals participated in this study: 12 diagnosed with BDD (7 female) and 16 healthy controls (10 female) who were closely matched (see Table 1) with regard to age and IQ (National Adult Reading Test, NART; Nelson, 1982). Seven BDD participants were taking medication at the time of testing. All were taking one selective serotonin reuptake inhibitor (SSRI; Paroxetine [n¼1], Citalopram [n¼ 1], Escitalopram [n¼ 3] and Sertraline [n¼2]). Five were also taking one adjunctive antipsychotic medication (Risperidone [n¼ 1], Aripiprazole [n¼ 1], Quetiapine [n¼ 3]). None of the control participants were receiving psychotropic medication. Individuals in the BDD group were recruited from the OCD and BDD specialty outpatient clinic of one of the authors (NAF). All received a diagnosis of BDD from a senior clinician and OCD/BDD expert (NAF) using an extended clinical interview complemented by assessment using clinical scales such as the Yale Brown Obsessive Compulsive Scale for Body Dysmorphic Disorder (BDD-YBOCS; ˚ Rasmussen & Goodman, 2000), the Montgomery–Asberg Depression Rating Scale (MADRS, Montgomery & Asberg, 1979) and the Hamilton Anxiety Scale (HAM-A, Hamilton, 1959). All of the BDD participants fulfilled DSM IV criteria for this condition, and BDD was their primary diagnosis. All also had at least one comorbid disorder, with most participants having two or more of the following comorbidities: Obsessive Compulsive Disorder (OCD), Major Depressive Disorder, Obsessive Compulsive Personality Disorder (OCPD), Social Anxiety Disorder (SAD), Tourette’s and Gender Identity Disorder, all of which were diagnosed using DSM-IV criteria. None of the participants in the control group had any psychological disorders. The mean duration of illness for the 12 BDD patients was 11.13 years. BDD severity was measured using the BDD-YBOCS. All participants were also administered the MADRS and the HAM-A to assess depression and anxiety. As expected (see Table 1), the BDD group showed a significantly higher level of depression and anxiety as compared to the controls. We therefore ran all statistical analyses with and without covarying for both anxiety and depression; however the overall patterns of results did not differ. Table 1 Means and standard deviations for demographic details. BDD
Age (years) NART IQ Education (years) HAM-A MADRS BDD-YBOCS
Control
Mean
SD
Mean
SD
30.08 113.80 14.08
(8.92) (2.95) (1.88)
35.80 115.00 14.41
(12.10) (3.34) (1.99)
8.08 7.50 13.25
(6.75) (5.98) (4.88)
3.94 2.50 2.38
(3.04) (4.29) (3.40)
F
p 1.87 0.22 0.23
4.76 6.66 48.40
Cohen’s d 0.18 0.64 0.64
0.51 0.37 0.16
0.03 0.01 o 0.001
0.81 0.96 2.58
˚ Note: HAM-A—Hamilton Anxiety Test, MADRS—Montgomery–Asberg Depression Rating Scale, YBOCS—Yale Brown Obsessive Compulsive Scale for BDD, IFFT—Inverted Famous Faces Task.
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2.2. Face processing tasks 1. FEEST. In the FEEST, 60 photos of faces are presented in a random order for five seconds each on a computer screen, with 10 photos for each of the six basic emotions from the Ekman and Friesen (1976) series (happiness, surprise, fear, sadness, disgust, anger). Participants are required to choose the label that best describes the emotion displayed by each face and indicate their answer by using the laptop touch pad to click on their chosen response. The Ekman 60 Faces Test from the Facial Expression of Emotions: Stimulus and Test (FEEST: Young, Perrett, Calder, Sprengelmeyer, & Ekman, 2002) is a reliable and valid measure of emotion recognition (Young et al., 2002). 2. Famous Faces Task. The Famous Faces Task (FFT) comprises 50 grey-scale photographs of a range of famous people, including actors, musicians, politicians and sportspeople from past and present times. Participants are required to watch the screen and verbally identify the famous person to the researcher first in the inverted position (without tilting their head at all in an attempt to view the image the correct way) and then upright. All participants took the test in the upright condition more than 6 months subsequent to the inverted condition.
2.3. Procedure Participants who agreed to participate attended the QEII Hospital for testing in a room designated for research purposes. Upon arrival, they were asked to read and sign the study’s consent form. Participants were first asked to complete the FEEST task (described in Section 2.2) which took approximately 10 min. They then completed the famous faces task, which was presented using a laptop and controlled by the experimenter. Participants were asked to name the famous person without tilting their head (in the inverted condition). Scores were based on whether the participant could correctly name each famous face. The study’s protocol was favourably reviewed by the East London and the City Research Ethics Committee (REC) and ethical approval was subsequently gained from this REC and that of the University of Hertfordshire.
Fig. 1. Number of threat and no-threat emotions recognised by BDD and control groups. Note: Error bars denote standard deviation.
3. Results 1. FEEST. All six emotions from the FEEST were analysed using MANOVA (see Table 2) and revealed only one significant difference: the BDD group recognised fearful emotions significantly less well than did the control group. Emotions on the FEEST task were then split into categories representing ‘‘threat’’ (fear, anger, disgust) and ‘‘no-threat’’ (happiness, sadness, surprise). Fig. 1 illustrates the main effect of face type that was detected: the BDD group recognised expressions categorised as ‘‘no-threat’’ better than those categorised as ‘‘threat’’ emotions (F(1, 24) ¼16.59, po0.001, partial Z2 ¼0.41). The interaction between group and face type was significant (F(1, 24) ¼8.50, p ¼0.008, partial Z2 ¼0.26), whereas there was no significant main effect for group (F(1, 24)¼3.38, p ¼0.08, partial Z2 ¼0.12). 2. Famous faces. A two-way repeated measures ANOVA revealed a significant interaction (see Fig. 2) between image orientation and group (F (1, 26)¼21.25, p ¼ o0.001, partial Z2 ¼0.45). The BDD patients correctly named significantly more faces than the control group in the inverted condition (M ¼33.96; SD¼3.95 vs. M¼22.75; SD¼7.7; t¼4.59, df ¼26, p o0.001: Table 2 Means and standard deviations for FEEST facial emotion processing task. BDD
Anger Disgust Fear Happiness Sadness Surprise Total
Control
Mean
SD
Mean
SD
F
p
Cohen’s d
6.75 8.00 5.08 9.92 8.67 8.58 47.00
(1.14) (1.41) (2.75) (0.29) (1.72) (1.31) (3.72)
7.75 8.63 7.69 9.88 8.06 8.50 50.44
(1.29) (0.96) (1.66) (0.34) (1.91) (1.32) (3.93)
1.49 3.57 4.53 0.08 0.32 0.04 3.29
0.23 0.07 0.04n 0.79 0.57 0.84 0.08
0.79 0.52 1.16 0.12 0.32 0.06 0.87
Fig. 2. Number of famous faces correctly named in on the Famous Faces task in the upright and inverted conditions. Note: Error bars denote standard deviation.
d¼1.82), whereas the upright condition did not yield a significant difference between groups (M¼48.67; SD¼ 1.37 vs. M ¼47.81; SD¼2.13; t¼ 1.2, df¼ 26, p¼0.24: d ¼0.48). A significant main effect was found for group type (F(1, 26)¼17.65, p ¼ o0.001, partial Z2 ¼0.404) and for image orientation (F(1, 26) ¼260.47, p ¼ o0.001, partial Z2 ¼0.909).
4. Discussion In the current study, we compared identity and emotion face processing abilities in patients with BDD and in healthy control individuals. Compared to the control group, BDD patients were superior at recognising inverted famous faces (even though no difference emerged for normal orientation of faces). On the emotion recognition task, the BDD participants identified significantly fewer fearful faces. While their performance did not differ significantly on the other five emotional expressions, the effect sizes were moderate to large for negative emotional expressions including anger and disgust. This suggests that our small sample size may have been underpowered to detect more between-group differences. Like the control group, the BDD group most commonly
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mistook fear for surprise and sadness, which differs from previous studies that have indicated a tendency of BDD patients to misinterpret facial expressions as angry (Buhlmann et al., 2004; Buhlmann et al., 2006). The results from the threat-no threat analysis showed a significantly better recognition of non-threat stimuli by the BDD group. In contrast to the generally poor ability to recognise (negative) facial expressions, individuals with BDD correctly recognised significantly more inverted famous faces than did the matched controls. Future research might investigate inverted face recognition as a marker for BDD. While superior inverted recognition has been documented in one patient group (Williams Syndrome, e.g. Isaac & Lincoln, 2011), it has been documented in healthy individuals described as so-called ‘‘super-recognisers’’ (Russell, Duchaine & Nakayama, 2009) who show exceptional familiar face recognition. Not necessarily therefore an indicator of pathology as much as atypicality, the achievement of a high level of performance on this task does not guarantee normal underlying processes (Karmiloff-Smith et al., 2004). Neuropsychological studies of patients with impairments in visual processing provide evidence that upright and inverted faces are indeed represented using distinct cognitive mechanisms (Farah, 2004; Yin, 1970). Individuals with BDD might perform better on the inverted faces task owing to an increased tendency to focus on single features of the face, which is akin to their preoccupation with their own facial features. Stangier et al. (2008) used a picture of a female face and digitally altered specific features (hair loss, scars, size of the nose and so on) to find that individuals with BDD showed a preference for identifying facial features as opposed to the face as a whole. An alternative explanation of our finding is that BDD patients are simply better at the recognition and recall of detailed visual information per se. The latter seems less likely given that, while individuals with BDD show a tendency to remember the details about complex shapes and not the overall outline, other research shows that their performance is worse than healthy controls on measures of organisational strategies when undertaking the Rey–Osterrieth Figure Test (Deckersbach et al., 2000). It is also important to consider that individuals with BDD are likely to attend in more detail to famous faces portrayed in the media. Owing to the nature of BDD, the propensity for patients to analyse their own facial features might also make them more likely to observe features more closely in the faces of others. Hence, they might also attend more to the media, giving them greater exposure than the healthy control group to some of the individuals presented in the Famous Faces Task. Nonetheless, the groups did not differ in naming upright faces, thus the faces were as well-known to the controls as to the BDD group. If familiarity is relevant, then it might be specific to the inverted recognition of familiar faces. Thus, it is possible that the BDD patients were using a different face processing strategy than the control group. Results from the threat analysis showed that the BDD group had difficulty recognising threatening, but not non-threatening expressions. The propensity for individuals with BDD to recognise faces by their constituent parts may, on one hand, be beneficial (e.g. for the recognition of inverted faces), but on the other hand be detrimental to the recognition of threatening faces as these expressions may carry less useful information than a non-threatening expression. It may also be the case that individuals become desensitised to the experience of fear as an artefact of having BDD and the tendency to over-interpret fear in real life social situations. Another possible explanation for the better performance of controls in the recognition of fear is that individuals with BDD show a specific hypersensitivity to the emotion of fear as a result of experiencing this emotion excessively as part of their BDD. Therefore, they may focus on other parts of the face and avoid
looking at the eyes, which is an important part of recognising the fear expression. This could be further explored by mapping eye gaze in BDD to track the specific parts of the face that individuals with BDD attend do, compared with controls. Thus, an individual with BDD looking at a fearful face may experience an exaggerated level of anxiety, which interferes with the ability to process that emotion properly. Further exploration of state anxiety in BDD (e.g. using galvanic skin response measurement during facial emotional processing) might help clarify this possibility.
4.1. Limitations The present study has a number of limitations that should be considered. First, the size of our BDD group was relatively small, which has implications for power. Our nonsignificant findings (e.g. with negative emotions) might reflect low power and therefore require further study with larger samples. Second, because the present study lacked a psychiatric comparison group (e.g., with social phobia), we cannot rule out that our findings reflect processes that are not specific to BDD. A third limitation is the presence of comorbid conditions in our sample, which cannot be ruled out as accounting for the observed results. Most people with BDD, however, have at least one comorbid disorder (Gunstad & Phillips, 2003); one study reported comorbidity rates of 88% with mood disorder and 60% with anxiety disorders (Phillips & Diaz, 1997). These comorbidities raise the issue of whether or not to control for anxiety and depression or to view them as integral aspects of BDD that should not be factored out in either patient selection or statistical covariance. Although we did not find differences in the present study, this requires consideration in future research. It is also worth considering that although the BDD group evidenced depressive symptoms, the mean MADRS score (7.50; SD 5.98) did not fall within the sereve range. Other studies have also reported mild to moderate depressive symptoms in BDD patients (e.g. Phillips, Siniscalchi, & McElroy, 2004). Investigating face processing abilities in the unaffected relatives of BDD patients (who may share predisposing vulnerabilities) may allow us to disentangle the impact of state versus trait factors. Finally, the use of medication (and SSRIs in particular) within the BDD group may have contributed to differences in response structure between our two groups. Studies have reported attenuated behavioural and brain (amygdala) responses in healthy controls to aversive stimuli such as negative facial emotions after acute single-dose (but not chronic) SSRI administration (Del-Ben et al., 2005; Anderson et al., 2007; Bigos et al., 2008; Murphy, Norbury, O’Sullivan, Cowen, & Harmer, 2009). On the other hand, a recent study on disgust recognition in obsessive compulsive disorder, a disorder with many similarities to BDD, found that chronic SSRI failed to normalise abnormal disgust recognition under a pharmacological challenge. The authors hypothesised that abnormal face processing in OCD represents a trait phenomenon (Lochner et al., 2012). In addition, one study in the depressed elderly has reported that chronic SSRI improved the recognition of negative as well as positive faces in BDD patients ¨ ¨ ¨ (Savaskan, Muller, Bohringer, Schulz, & Schachinger, 2008). Examination of untreated BDD cases are required to clarify these issue points, although such cases are difficult to identify even in a specialist treatment-centre such as ours.
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Journal of Obsessive-Compulsive and Related Disorders journal homepage: www.elsevier.com/locate/jocrd
Superior face recognition in Body Dysmorphic Disorder Kiri Jefferies a,b,n, Keith R. Laws a, Naomi A. Fineberg b a b
University of Hertfordshire School of Psychology, College Lane, Hatfield, Hertfordshire AL10 9AB, UK National OCD Specialist Service, Herts Partnership NHS Foundation Trust, Queen Elizabeth II Hospital, Welwyn Garden City, Herts, UK
a r t i c l e i n f o
abstract
Article history: Received 27 September 2011 Received in revised form 12 March 2012 Accepted 14 March 2012 Available online 4 April 2012
Introduction: Individuals with Body Dysmorphic Disorder (BDD) may have a propensity for viewing faces differently from healthy controls. In an attempt to explore these processing changes in more detail, we investigate face processing in BDD using two facial recognition tasks; one testing the recognition of facial characteristics, the other testing the recognition of facial expressions of emotion. Method: Participants with BDD (n ¼ 12) and healthy controls (n ¼ 16) were tested for inverted face recognition using the Famous Faces Task (FFT) and the Facial Expression of Emotions Stimulus and Test emotion recognition task (FEEST). The groups were matched for age, IQ and education. Results: Participants with BDD showed a significant ability to correctly recognise inverted famous faces compared to well-matched controls. In contrast, participants with BDD showed a specific deficit in recognising fearful facial emotions. BDD participants excel over controls at performing the FFT. Conclusions: These findings may represent a cognitive marker for BDD. The specific deficit within the BDD group for recognising fearful expressions may be another feature of the disorder and may implicate abnormal processing of negatively valenced emotional material. The specificity of these findings for BDD merit further investigation using other clinical groups and a larger sample size. & 2012 Elsevier Ltd All rights reserved.
Keywords: Body Dysmorphic Disorder Obsessive compulsive disorder Face Anxiety
1. Introduction Body Dysmorphic Disorder (BDD), the obsessive preoccupation with perceived defects in appearance, has been estimated to affect 1–2% of the population (Rief, Buhlmann, Wilhelm, Borkenhagen, & Br¨ahler, 2006). Individuals with BDD are concerned they have a bodily imperfection that they consider unsightly, and they fear subsequent negative evaluation by others. In some cases, they exaggerate a trivial flaw; in other cases they are troubled by an imaginary defect. The symptoms of BDD are associated with considerable distress, and in one study (Eisen, Phillips, Coles, & Rasmussen, 2004), as many as 39% of BDD individuals appeared to lack insight into their fixed, false beliefs. Moreover, in an attempt to minimise or hide the defect, or to disconfirm their fears, individuals with BDD engage in time-consuming compulsive behaviours, such as mirror checking (Veale, 2001), applying makeup (camouflaging) and seeking reassurance about their appearance (Goodman et al., 1989). In an attempt to reduce distress, they often engage in social avoidance.
n Corresponding author at: University of Hertfordshire School of Psychology, College Lane, Hatfield, Hertfordshire AL10 9AB, UK. Tel.: þ44 7736 048 630; fax: þ 44 1707 365 169. E-mail addresses: [email protected] (K. Jefferies), [email protected] (K.R. Laws), [email protected] (N.A. Fineberg).
2211-3649/$ - see front matter & 2012 Elsevier Ltd All rights reserved. http://dx.doi.org/10.1016/j.jocrd.2012.03.002
The most common preoccupation in BDD patients is with facial appearance (Phillips, 1996), frequently focusing on specific facial features with which they are unhappy, but also checking the appearance and facial features of others to make comparisons with their own. Grocholewski, Kliem, and Heinrichs (in press) examined eye tracking in individuals with BDD, social anxiety and healthy controls when looking at their own and others’ faces. Only patients with BDD showed heightened fixation to an imagined defect in their own face, but also to corresponding regions in unfamiliar faces, supporting the notion of a specific attentional bias in BDD. Imaging studies point to greater left hemisphere activity thought indicative of greater encoding and analysis of detail as opposed to more holistic and configural processing of faces in BDD (Feusner, Townsend, Bystritsky, & Bookheimer, 2007). Imaging has also documented visual processing and fronto-striatal differences when individuals with BDD are viewing their own face (Feusner et al., 2010c) and that the brain activity in these systems correlates with symptom severity. Obviously, facial expressions are a key way through which we express positive or negative thoughts, feelings and attitudes. Given the fear of negative evaluation and the frequent ideas of reference (e.g., that others are staring at them), individuals with BDD might be especially sensitive to facial expressions. For example, they might misinterpret a neutral facial expression as negative (Buhlmann, McNally, Etcoff, Tuschen-Caffier, & Wilhelm, 2004;
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Buhlmann, Etcoff, & Wilhelm, 2006). Research examining aspects of facial emotion recognition suggests that compared with controls, individuals with BDD have poorer recognition of negatively valenced facial emotions, especially when viewed from their own ‘perspective’ (Williams, Watts, MacLeod, & Mathews, 1997; Buhlmann, McNally, Wilhelm, & Florin, 2002). According to Buhlmann et al. (2004), compared with healthy controls and patients with obsessive-compulsive disorder (OCD), those with BDD show a bias toward misinterpreting facial expressions as angry, including neutral but also disgusted expressions. A later study by Buhlmann et al. (2006) found that individuals with BDD misinterpreted expressions as angry in ‘‘self-referent’’ situations (imagining themselves in a situation) but not in ‘‘other-referent’’ situations. Buhlmann, Gleiss, Rupf, Zschenderlein, and Kathmann (2011) also found that compared to healthy controls and individuals with dermatological conditions, BDD patients were more likely to misinterpret neutral expressions as negative emotions. These findings suggest that individuals with BDD believe other people share their own negative appraisal of their appearance; which might serve to maintain the disorder. In a thematic analysis, which included a qualitative analysis of conversation guided by self-portraits, Silver, Reavey, and Fineberg (2010) found a tendency for individuals with BDD to focus on facial detail rather than view the face as a whole. The most common theme was a heightened threat perception characterised by the participants being very sensitive to comments made by others that they interpreted as being critical of themselves. In addition, the majority of the participants expressed a wish for facial symmetry, possibly indicating a tendency to view the face in separate parts as opposed to as a whole. Consistent with this ¨ finding, Stangier, Adam-Schwebe, Muller, and Wolter (2008) reported that BDD patients were significantly more accurate than controls in detecting changes in photographs that are manipulated with regard to facial features (hair loss, scars size of the nose, etc.). A recently published study (Feusner et al., 2010b) investigated inverted face identification in individuals with BDD compared with healthy controls. Participants viewed upright photographs of unfamiliar faces (judged to be of average attractiveness) for 5000 ms, 3000 ms or 500 ms and were then asked to select from two photographs the picture that was the same as the target face. Compared with the control group, the BDD group was significantly faster when given 5000 ms; however, no group difference emerged for shorter viewing times. No evidence of a significant accuracy difference emerged between the two groups for any trial. The authors suggested that the extra time taken to view the image may allow a partial ‘decomposition’ of the face into constituent parts that is processed particularly well by BDD sufferers. Recognition of emotional expressions was also recently studied by Feusner, Bystritsky, Hellemann, and Bookheimer, (2010a) in which individuals with and without BDD were asked to match identities of faces to their emotional expressions. Participants also completed a control task matching ovals and circles instead of faces. The BDD group made twice as many errors as control subjects when matching faces to their emotional expressions, irrespective of the nature of the expression, but did not differ on the control task. This result suggests a rather general impairment in the processing of facial expressions. A high incidence of comorbidity exists within the BDD population and most commonly in the form of depression and social anxiety disorder (SAD: Phillips, & Diaz, 1997; NezirogluMcKay, Todaro, & Yaryura-Tobias, 1996; Veale et al., 1996). SAD is a disorder characterised by intense avoidance of social situations owing to the fear of negative evaluation by others. In this respect, SAD may be difficult to distinguish from BDD in the clinical scenario. Patients with SAD also show an abnormality in recognising facial expressions. Moriya and Tanno (2011) conducted a
task in which individuals with SAD with high anxiety, low anxiety and healthy controls were asked to view neutral and angry faces. Individuals with high anxiety had difficulty disengaging with the angry stimulus, suggesting a bias for and misinterpretation of threatening faces. Other research using dynamic stimuli (pictures of faces slowly morphing from neutral to a full expression of happiness, sadness, fear, etc.) suggests that individuals with SAD misinterpret threatening faces and show an inability to disengage from the image when they have to identify them quickly and efficiently. The present study examined facial emotion recognition and familiar face recognition for both upright and inverted faces in individuals with and without BDD. The research reviewed above leads to the hypothesis that individuals with BDD would show a bias toward misinterpreting facial expressions depicting negative emotions, and a tendency toward more effective identification of facial characteristics than controls that would become more evident with increasing difficulty i.e. when the image is inverted.
2. Method 2.1. Participants Twenty-eight individuals participated in this study: 12 diagnosed with BDD (7 female) and 16 healthy controls (10 female) who were closely matched (see Table 1) with regard to age and IQ (National Adult Reading Test, NART; Nelson, 1982). Seven BDD participants were taking medication at the time of testing. All were taking one selective serotonin reuptake inhibitor (SSRI; Paroxetine [n¼1], Citalopram [n¼ 1], Escitalopram [n¼ 3] and Sertraline [n¼2]). Five were also taking one adjunctive antipsychotic medication (Risperidone [n¼ 1], Aripiprazole [n¼ 1], Quetiapine [n¼ 3]). None of the control participants were receiving psychotropic medication. Individuals in the BDD group were recruited from the OCD and BDD specialty outpatient clinic of one of the authors (NAF). All received a diagnosis of BDD from a senior clinician and OCD/BDD expert (NAF) using an extended clinical interview complemented by assessment using clinical scales such as the Yale Brown Obsessive Compulsive Scale for Body Dysmorphic Disorder (BDD-YBOCS; ˚ Rasmussen & Goodman, 2000), the Montgomery–Asberg Depression Rating Scale (MADRS, Montgomery & Asberg, 1979) and the Hamilton Anxiety Scale (HAM-A, Hamilton, 1959). All of the BDD participants fulfilled DSM IV criteria for this condition, and BDD was their primary diagnosis. All also had at least one comorbid disorder, with most participants having two or more of the following comorbidities: Obsessive Compulsive Disorder (OCD), Major Depressive Disorder, Obsessive Compulsive Personality Disorder (OCPD), Social Anxiety Disorder (SAD), Tourette’s and Gender Identity Disorder, all of which were diagnosed using DSM-IV criteria. None of the participants in the control group had any psychological disorders. The mean duration of illness for the 12 BDD patients was 11.13 years. BDD severity was measured using the BDD-YBOCS. All participants were also administered the MADRS and the HAM-A to assess depression and anxiety. As expected (see Table 1), the BDD group showed a significantly higher level of depression and anxiety as compared to the controls. We therefore ran all statistical analyses with and without covarying for both anxiety and depression; however the overall patterns of results did not differ. Table 1 Means and standard deviations for demographic details. BDD
Age (years) NART IQ Education (years) HAM-A MADRS BDD-YBOCS
Control
Mean
SD
Mean
SD
30.08 113.80 14.08
(8.92) (2.95) (1.88)
35.80 115.00 14.41
(12.10) (3.34) (1.99)
8.08 7.50 13.25
(6.75) (5.98) (4.88)
3.94 2.50 2.38
(3.04) (4.29) (3.40)
F
p 1.87 0.22 0.23
4.76 6.66 48.40
Cohen’s d 0.18 0.64 0.64
0.51 0.37 0.16
0.03 0.01 o 0.001
0.81 0.96 2.58
˚ Note: HAM-A—Hamilton Anxiety Test, MADRS—Montgomery–Asberg Depression Rating Scale, YBOCS—Yale Brown Obsessive Compulsive Scale for BDD, IFFT—Inverted Famous Faces Task.
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2.2. Face processing tasks 1. FEEST. In the FEEST, 60 photos of faces are presented in a random order for five seconds each on a computer screen, with 10 photos for each of the six basic emotions from the Ekman and Friesen (1976) series (happiness, surprise, fear, sadness, disgust, anger). Participants are required to choose the label that best describes the emotion displayed by each face and indicate their answer by using the laptop touch pad to click on their chosen response. The Ekman 60 Faces Test from the Facial Expression of Emotions: Stimulus and Test (FEEST: Young, Perrett, Calder, Sprengelmeyer, & Ekman, 2002) is a reliable and valid measure of emotion recognition (Young et al., 2002). 2. Famous Faces Task. The Famous Faces Task (FFT) comprises 50 grey-scale photographs of a range of famous people, including actors, musicians, politicians and sportspeople from past and present times. Participants are required to watch the screen and verbally identify the famous person to the researcher first in the inverted position (without tilting their head at all in an attempt to view the image the correct way) and then upright. All participants took the test in the upright condition more than 6 months subsequent to the inverted condition.
2.3. Procedure Participants who agreed to participate attended the QEII Hospital for testing in a room designated for research purposes. Upon arrival, they were asked to read and sign the study’s consent form. Participants were first asked to complete the FEEST task (described in Section 2.2) which took approximately 10 min. They then completed the famous faces task, which was presented using a laptop and controlled by the experimenter. Participants were asked to name the famous person without tilting their head (in the inverted condition). Scores were based on whether the participant could correctly name each famous face. The study’s protocol was favourably reviewed by the East London and the City Research Ethics Committee (REC) and ethical approval was subsequently gained from this REC and that of the University of Hertfordshire.
Fig. 1. Number of threat and no-threat emotions recognised by BDD and control groups. Note: Error bars denote standard deviation.
3. Results 1. FEEST. All six emotions from the FEEST were analysed using MANOVA (see Table 2) and revealed only one significant difference: the BDD group recognised fearful emotions significantly less well than did the control group. Emotions on the FEEST task were then split into categories representing ‘‘threat’’ (fear, anger, disgust) and ‘‘no-threat’’ (happiness, sadness, surprise). Fig. 1 illustrates the main effect of face type that was detected: the BDD group recognised expressions categorised as ‘‘no-threat’’ better than those categorised as ‘‘threat’’ emotions (F(1, 24) ¼16.59, po0.001, partial Z2 ¼0.41). The interaction between group and face type was significant (F(1, 24) ¼8.50, p ¼0.008, partial Z2 ¼0.26), whereas there was no significant main effect for group (F(1, 24)¼3.38, p ¼0.08, partial Z2 ¼0.12). 2. Famous faces. A two-way repeated measures ANOVA revealed a significant interaction (see Fig. 2) between image orientation and group (F (1, 26)¼21.25, p ¼ o0.001, partial Z2 ¼0.45). The BDD patients correctly named significantly more faces than the control group in the inverted condition (M ¼33.96; SD¼3.95 vs. M¼22.75; SD¼7.7; t¼4.59, df ¼26, p o0.001: Table 2 Means and standard deviations for FEEST facial emotion processing task. BDD
Anger Disgust Fear Happiness Sadness Surprise Total
Control
Mean
SD
Mean
SD
F
p
Cohen’s d
6.75 8.00 5.08 9.92 8.67 8.58 47.00
(1.14) (1.41) (2.75) (0.29) (1.72) (1.31) (3.72)
7.75 8.63 7.69 9.88 8.06 8.50 50.44
(1.29) (0.96) (1.66) (0.34) (1.91) (1.32) (3.93)
1.49 3.57 4.53 0.08 0.32 0.04 3.29
0.23 0.07 0.04n 0.79 0.57 0.84 0.08
0.79 0.52 1.16 0.12 0.32 0.06 0.87
Fig. 2. Number of famous faces correctly named in on the Famous Faces task in the upright and inverted conditions. Note: Error bars denote standard deviation.
d¼1.82), whereas the upright condition did not yield a significant difference between groups (M¼48.67; SD¼ 1.37 vs. M ¼47.81; SD¼2.13; t¼ 1.2, df¼ 26, p¼0.24: d ¼0.48). A significant main effect was found for group type (F(1, 26)¼17.65, p ¼ o0.001, partial Z2 ¼0.404) and for image orientation (F(1, 26) ¼260.47, p ¼ o0.001, partial Z2 ¼0.909).
4. Discussion In the current study, we compared identity and emotion face processing abilities in patients with BDD and in healthy control individuals. Compared to the control group, BDD patients were superior at recognising inverted famous faces (even though no difference emerged for normal orientation of faces). On the emotion recognition task, the BDD participants identified significantly fewer fearful faces. While their performance did not differ significantly on the other five emotional expressions, the effect sizes were moderate to large for negative emotional expressions including anger and disgust. This suggests that our small sample size may have been underpowered to detect more between-group differences. Like the control group, the BDD group most commonly
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mistook fear for surprise and sadness, which differs from previous studies that have indicated a tendency of BDD patients to misinterpret facial expressions as angry (Buhlmann et al., 2004; Buhlmann et al., 2006). The results from the threat-no threat analysis showed a significantly better recognition of non-threat stimuli by the BDD group. In contrast to the generally poor ability to recognise (negative) facial expressions, individuals with BDD correctly recognised significantly more inverted famous faces than did the matched controls. Future research might investigate inverted face recognition as a marker for BDD. While superior inverted recognition has been documented in one patient group (Williams Syndrome, e.g. Isaac & Lincoln, 2011), it has been documented in healthy individuals described as so-called ‘‘super-recognisers’’ (Russell, Duchaine & Nakayama, 2009) who show exceptional familiar face recognition. Not necessarily therefore an indicator of pathology as much as atypicality, the achievement of a high level of performance on this task does not guarantee normal underlying processes (Karmiloff-Smith et al., 2004). Neuropsychological studies of patients with impairments in visual processing provide evidence that upright and inverted faces are indeed represented using distinct cognitive mechanisms (Farah, 2004; Yin, 1970). Individuals with BDD might perform better on the inverted faces task owing to an increased tendency to focus on single features of the face, which is akin to their preoccupation with their own facial features. Stangier et al. (2008) used a picture of a female face and digitally altered specific features (hair loss, scars, size of the nose and so on) to find that individuals with BDD showed a preference for identifying facial features as opposed to the face as a whole. An alternative explanation of our finding is that BDD patients are simply better at the recognition and recall of detailed visual information per se. The latter seems less likely given that, while individuals with BDD show a tendency to remember the details about complex shapes and not the overall outline, other research shows that their performance is worse than healthy controls on measures of organisational strategies when undertaking the Rey–Osterrieth Figure Test (Deckersbach et al., 2000). It is also important to consider that individuals with BDD are likely to attend in more detail to famous faces portrayed in the media. Owing to the nature of BDD, the propensity for patients to analyse their own facial features might also make them more likely to observe features more closely in the faces of others. Hence, they might also attend more to the media, giving them greater exposure than the healthy control group to some of the individuals presented in the Famous Faces Task. Nonetheless, the groups did not differ in naming upright faces, thus the faces were as well-known to the controls as to the BDD group. If familiarity is relevant, then it might be specific to the inverted recognition of familiar faces. Thus, it is possible that the BDD patients were using a different face processing strategy than the control group. Results from the threat analysis showed that the BDD group had difficulty recognising threatening, but not non-threatening expressions. The propensity for individuals with BDD to recognise faces by their constituent parts may, on one hand, be beneficial (e.g. for the recognition of inverted faces), but on the other hand be detrimental to the recognition of threatening faces as these expressions may carry less useful information than a non-threatening expression. It may also be the case that individuals become desensitised to the experience of fear as an artefact of having BDD and the tendency to over-interpret fear in real life social situations. Another possible explanation for the better performance of controls in the recognition of fear is that individuals with BDD show a specific hypersensitivity to the emotion of fear as a result of experiencing this emotion excessively as part of their BDD. Therefore, they may focus on other parts of the face and avoid
looking at the eyes, which is an important part of recognising the fear expression. This could be further explored by mapping eye gaze in BDD to track the specific parts of the face that individuals with BDD attend do, compared with controls. Thus, an individual with BDD looking at a fearful face may experience an exaggerated level of anxiety, which interferes with the ability to process that emotion properly. Further exploration of state anxiety in BDD (e.g. using galvanic skin response measurement during facial emotional processing) might help clarify this possibility.
4.1. Limitations The present study has a number of limitations that should be considered. First, the size of our BDD group was relatively small, which has implications for power. Our nonsignificant findings (e.g. with negative emotions) might reflect low power and therefore require further study with larger samples. Second, because the present study lacked a psychiatric comparison group (e.g., with social phobia), we cannot rule out that our findings reflect processes that are not specific to BDD. A third limitation is the presence of comorbid conditions in our sample, which cannot be ruled out as accounting for the observed results. Most people with BDD, however, have at least one comorbid disorder (Gunstad & Phillips, 2003); one study reported comorbidity rates of 88% with mood disorder and 60% with anxiety disorders (Phillips & Diaz, 1997). These comorbidities raise the issue of whether or not to control for anxiety and depression or to view them as integral aspects of BDD that should not be factored out in either patient selection or statistical covariance. Although we did not find differences in the present study, this requires consideration in future research. It is also worth considering that although the BDD group evidenced depressive symptoms, the mean MADRS score (7.50; SD 5.98) did not fall within the sereve range. Other studies have also reported mild to moderate depressive symptoms in BDD patients (e.g. Phillips, Siniscalchi, & McElroy, 2004). Investigating face processing abilities in the unaffected relatives of BDD patients (who may share predisposing vulnerabilities) may allow us to disentangle the impact of state versus trait factors. Finally, the use of medication (and SSRIs in particular) within the BDD group may have contributed to differences in response structure between our two groups. Studies have reported attenuated behavioural and brain (amygdala) responses in healthy controls to aversive stimuli such as negative facial emotions after acute single-dose (but not chronic) SSRI administration (Del-Ben et al., 2005; Anderson et al., 2007; Bigos et al., 2008; Murphy, Norbury, O’Sullivan, Cowen, & Harmer, 2009). On the other hand, a recent study on disgust recognition in obsessive compulsive disorder, a disorder with many similarities to BDD, found that chronic SSRI failed to normalise abnormal disgust recognition under a pharmacological challenge. The authors hypothesised that abnormal face processing in OCD represents a trait phenomenon (Lochner et al., 2012). In addition, one study in the depressed elderly has reported that chronic SSRI improved the recognition of negative as well as positive faces in BDD patients ¨ ¨ ¨ (Savaskan, Muller, Bohringer, Schulz, & Schachinger, 2008). Examination of untreated BDD cases are required to clarify these issue points, although such cases are difficult to identify even in a specialist treatment-centre such as ours.
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