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Victimization, social anxiety, and body dysmorphic concerns: Appearance-based rejection sensitivity as a mediator
Body Image 11 (2014) 391–395
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Victimization, social anxiety, and body dysmorphic concerns: Appearance-based rejection sensitivity as a mediator Cassie H. Lavell ∗ , Melanie J. Zimmer-Gembeck, Lara J. Farrell, Haley Webb School of Applied Psychology & Griffith Health Institute, Griffith University, Gold Coast Campus, Australia
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Article history: Received 2 January 2014 Received in revised form 15 June 2014 Accepted 17 June 2014 Keywords: Body dysmorphic disorder Social anxiety Appearance-based victimization Appearance-based rejection sensitivity
Body dysmorphic disorder (BDD) is characterized by extreme preoccupation with perceived deficits in physical appearance, and sufferers experience severe impairment in functioning. Previous research has indicated that individuals with BDD are high in social anxiety, and often report being the victims of appearance-based teasing. However, there is little research into the possible mechanisms that might explain these relationships. The current study examined appearance-based rejection sensitivity as a mediator between perceived appearance-based victimization, social anxiety, and body dysmorphic symptoms in a sample of 237 Australian undergraduate psychology students. Appearance-based rejection sensitivity fully mediated the relationship between appearance-based victimization and body dysmorphic symptoms, and partially mediated the relationship between social anxiety and body dysmorphic symptoms. Findings suggest that individuals high in social anxiety or those who have a history of more appearance-based victimization may have a bias towards interpreting further appearance-based rejection, which may contribute to extreme appearance concerns such as BDD. © 2014 Elsevier Ltd. All rights reserved.
Introduction Body dysmorphic disorder (BDD) is characterized by preoccupation with perceived deficits in physical appearance, which are viewed as unattractive, abnormal or deformed (American Psychiatric Association, 2013). Preoccupation is a critical element of BDD and includes persistent thoughts about the perceived defect, but also involves behaviours that can interfere with day-to-day living, such as frequent attempts to camouflage or hide perceived defects, a compulsion to check appearance in mirrors, and excessive reassurance seeking from others (Phillips, Menard, Fay, & Weisberg, 2005). Very little is known about the aetiology or developmental pathways of BDD, but this disorder has drawn increasing research attention in recent years, partly due to its increasing presentation across specialist settings, outside of mental health care. For example, up to 12% of patients seen by dermatologists, and up to 15% of patients seeking cosmetic surgery meet the criteria for BDD (Thompson & Durrani, 2007). Furthermore, the seriousness of BDD is now widely accepted with evidence that this disorder is
∗ Corresponding author at: Griffith Health Institute, School of Applied Psychology, Griffith University, Gold Coast Campus, Queensland 4222, Australia. Tel.: +61 432611172. E-mail address: cassie.lavell@griffithuni.edu.au (C.H. Lavell). http://dx.doi.org/10.1016/j.bodyim.2014.06.008 1740-1445/© 2014 Elsevier Ltd. All rights reserved.
associated with profound impairment for sufferers, including high rates of suicidal ideation and attempts (Phillips & Menard, 2006). Thus, cognitive behavioural models have emerged that identify how symptoms may develop and be maintained over time. For example, Veale and colleagues (e.g., Neziroglu, Khemlani-Patel, & Veale, 2008) proposed a model that describes the maintenance of BDD symptoms via internal processes such as excessive selffocused attention, negative appraisals of body image, and rumination. It has also been proposed that predisposing factors, such as fear of negative evaluation and adverse social experiences (e.g., victimization, teasing, and abuse) lead to distorted processing of emotional and social input (Buhlmann & Wilhelm, 2004; Wilhelm & Neziroglu, 2002). These distortions result in high levels of distress and, in an attempt to neutralize these negative feelings, individuals with BDD perform ritualistic behaviours, seek reassurance, and avoid situations that trigger discomfort or anxiety. In a counterproductive manner, these safety and avoidance behaviours serve to maintain the disorder through temporary relief from negative emotions (Buhlmann & Wilhelm, 2004; Wilhelm & Neziroglu, 2002). Thus, this model suggests a pathway from early victimization and fear of negative evaluation (often measured as social anxiety symptoms) to BDD that occurs via appearance-related concerns and obsessions. Such appearance-related concerns have recently been described in research on appearance-based rejection sensitivity (appearance-RS). However, no previous research has tested such a model incorporating the roles of both social anxiety and
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appearance-based victimization in BDD, while also testing whether these associations are fully or partly mediated by appearance-RS. The purpose of this study was to investigate this mediational model in a sample of undergraduate university students. Appearance-based Victimization and Social Anxiety as Correlates of BDD Appearance-based victimization. In support of the view that there are social risks underlying the cognitions that mark BDD, BDD patients have been found to report being the victims of teasing or bullying in school, especially as related to their appearance. For example, in an investigation of spontaneously occurring images and early memories, Osman, Cooper, Hackmann, and Veale (2004) found that BDD patients’ memories typically involved themes of teasing and bullying about their appearance in school. Moreover, compared to controls, BDD patients report significantly greater perceived appearance-related verbal victimization from their childhood and adolescence (Buhlmann, Cooke, Fama, & Wilhelm, 2007), and recall these experiences as more traumatic (Buhlmann, Wilhelm, Glaesmer, Mewes, Brähler, & Rief, 2011). Social anxiety. Another risk factor for BDD appears to be social anxiety, especially fear of negative evaluation by others (Anson, Veale, & de Silva, 2012). Prevalence rates of social phobia in individuals with BDD tend to be high, ranging from 12% to 69% (Phillips & Diaz, 1997; Zimmerman & Mattia, 1998). Moreover, in studies of individuals with comorbid social phobia and BDD, the onset of social phobia tends to precede the onset of BDD (e.g., Coles et al., 2006). This provides further support for the risk stage of cognitive behavioural models, and could suggest social anxiety contributes to the development of BDD. However, despite the evidence that victimization, especially related to appearance, and social anxiety are important risk factors for BDD, there is little research into the possible mechanisms that might explain these relationships. Appearance-based Rejection Sensitivity as a Mediator and Aims of the Present Study Appearance-RS refers to the tendency to anxiously expect, readily perceive, and overreact to signs of rejection based on one’s physical appearance (Park, 2007). In samples of university students in the United Kingdom (Calogero, Park, Rahemtulla, & Williams, 2010) and United States (Park, Calogero, Young, & DiRaddo, 2010), appearance-RS has been found to be associated with greater BDD symptoms, suggesting concerns about appearance-based rejection may be important in understanding the development of BDD. Appearance-RS is modelled after Feldman and Downey’s (1994) construct of personal rejection sensitivity (personal-RS), which partially mediated the relationship between social anxiety and BDD symptoms in study of 218 undergraduate university students by Fang, Asnaani, Gutner, Cook, Wilhelm, and Hofmann (2011). In light of research that suggests appearance-RS may account for more unique variance in BDD severity than personal-RS (Kelly, Didie, & Phillips, 2014), it is possible that appearance-RS may also be an underlying mechanism in the relationship between social anxiety and BDD, and may account for more variance. Further, Feldman and Downey (1994) proposed that rejection sensitivity serves as a mediator between early experiences and processing of current information. Thus, it is possible that early experiences of appearance-based victimization may contribute to expectations of further rejection, which, in turn, might explain symptoms of BDD such as social avoidance or attempts to “fix” or improve one’s appearance (e.g., cosmetic surgery, excessive grooming, camouflaging) in order to prevent future rejection. Therefore, we examined whether appearance-RS was a potential mediator in explaining why appearance-based victimization
and social anxiety are associated with heightened body dysmorphic symptoms. This study extends the research of Fang et al. (2011) by incorporating appearance-based victimization into the model, and testing appearance-RS as an alternative mediator to personal-RS. The model was tested with a university sample, given the high rates of body concerns among this group (Bartsch, 2007). Specifically, it was hypothesized that (1) appearance-RS would mediate the relationship between social anxiety and body dysmorphic symptoms, and that (2) appearance-RS would mediate the relationship between perceived appearance-based victimization and body dysmorphic symptoms. Given the slightly higher prevalence of BDD in younger adults relative to older adults, and higher prevalence in women relative to men (Buhlmann et al., 2010; Koran, Abujaoude, Large, & Serpe, 2008; Rief, Buhlmann, Wilhelm, Borkenhagen, & Brähler, 2006), age and gender were included as covariates in the model. Method Participants The participants were 237 Australian first-year university students (74% female) aged 17–42 years (Mage = 21.13 years, SD = 4.86). The majority of participants were Australian-born (79%), with English as their first spoken language (91%). Measures Body dysmorphic symptoms. The 10-item Appearance Anxiety Inventory (AAI; Veale, Eshkevari, Kanakam, Ellison, Costa, & Werner, 2013) was used to measure body dysmorphic symptoms. The scale has two factors: (1) avoidance, which reflects camouflaging and avoidance behaviours, and (2) threat monitoring, which reflects checking, rumination, and reassurance seeking. Participants rated each item on a 5-point scale (0 = Not at all, 4 = All the time). Total scores were created by summing the items. While the AAI is a relatively new measure, Veale et al. (2013) found that the scale discriminated between individuals with a diagnosis of BDD and individuals without a diagnosis, and had good convergent validity (r = .55) with the Yale-Brown Obsessive Compulsive Scale modified for BDD (Veale et al., 2013). Cronbach’s ˛ in the current study was .90 for total symptoms, .89 for avoidance, and .73 for threat monitoring. Appearance-based rejection sensitivity. The 15-item Appearance-based Rejection Sensitivity Scale (Park, 2007) was used to measure participants’ appearance-based expectations of rejection. Participants read 15 scenarios and indicated how concerned or anxious they would feel about being rejected on a 6-point scale (1 = Very unconcerned, 6 = Very concerned), and how much they would expect rejection (1 = Very unlikely, 6 = Very likely). Total scores reflect the mean of all scenarios’ anxious concern score multiplied by expectation score. In the present study, Cronbach’s ˛ was .96. Social anxiety. The 18-item Social Anxiety Scale for Adolescents (La Greca & Lopez, 1998) was used to assess fear of negative evaluation, social avoidance, and distress in social situations. Items were rated on a 5-point scale (1 = Not true, 5 = Very true) and items were summed to form total scores. This measure has demonstrated convergent validity with other social anxiety measures and discriminant validity with measures of depression (Inderbitzen-Nolan & Walters, 2000). In the present study, Cronbach’s ˛ was .95. Appearance-based verbal victimization. A modified version of the Perceptions of Teasing Scale (Thompson, Cattarin, Fowler, & Fisher, 1995) was used to measure the frequency of perceived verbal victimization experienced between ages 5 and 16 years. The
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Table 1 Means, standard deviations, and bivariate correlations between all measures. Variable
M
SD
1
1. Body dysmorphic symptoms 2. Avoidance 3. Threat monitoring 4. Social anxiety 5. Appearance-based victimization 6. Appearance-RS
11.98 7.10 4.97 46.34 12.84 13.35
7.82 5.43 3.14 16.03 5.31 7.65
– .96 .87 .58 .29 .71
2
3
4
5
– .70 .58 .31 .71
– .46 .19 .58
– .32 .64
– .33
Note: All ps < .01.
original measure had 11 items consisting of two subscales: weightrelated teasing (6 items) and competence-related teasing (5 items). In the current study, the authors modified weight-related items to assess appearance-related victimization (e.g., “People made fun of you because you were heavy” was changed to “People made fun of you because of your appearance”). The frequency of each item was rated on a 5-point scale (1 = Never, 5 = Very often). The scale also assesses victimization distress. However, only items related to the frequency of appearance-based victimization were included in the analyses. Summing the six appearance-related items formed the total scores. In the present study, Cronbach’s ˛ was .85. Procedure Following ethical approval by the university Human Research Ethics Committee, a 30-min online questionnaire was administered to first-year psychology students attending university on the Gold Coast, Australia. The study was advertised via a university webpage that listed various research projects recruiting first-year student participants. All students received 0.5% course credit for their participation. An information page was provided on the first page of the questionnaire, including a description of the study, the risks and benefits, the opportunity for debriefing, confidentiality, and informed consent. Statistical Analyses Distributions and unusual scores were examined via scatterplots, studentized residuals, leverage scores, and Cook’s D. No individual cases were deleted or transformed. Pearson correlation coefficients were calculated to determine the associations among variables. The mediational model was tested using the Process macro (Hayes, 2013), with social anxiety and appearance-based verbal victimization as independent variables, body dysmorphic symptoms as the dependent variable, and appearance-RS as the mediator (see Fig. 1). Age and gender were entered as covariates. The same model was also tested with the two factors of the AAI, avoidance and threat monitoring, as dependent variables. For fully mediated effects to occur, direct pathways from the independent variables to the dependent variable should be non-significant after controlling for the mediator. Kappa squared (k2 ) effect size statistics were calculated for each of the indirect effects. k2 represents
Social anxiety
.32*** .15* Appearance-based victimization
Appearance-based rejection sensitivity
Results Means, standard deviations, and bivariate correlations among all variables are presented in Table 1. All variables met the criteria for mediation analysis with significant associations in the expected directions, all ps < .001. As shown in Table 2, social anxiety and appearance-based victimization were both uniquely associated with appearance-RS in a regression model. Appearance-RS was, in turn, significantly associated with body dysmorphic symptoms after controlling for the two independent variables (Table 3). Bootstrapped 95% confidence intervals (95% CI) showed that the indirect effect of appearance-based victimization on body dysmorphic symptoms via appearance-RS was significant (b = .12, 95% CI = .03–.23, k2 = .09). The direct effect of appearance-based victimization on body dysmorphic symptoms was not significant after controlling for appearance-RS (b = .07, 95% CI = −.07 to .21), suggesting full mediation of the association between victimization and symptoms via appearance-RS. The indirect pathway from social anxiety to body dysmorphic symptoms via appearance-RS was also significant (b = .16, 95% CI = .11–.21, k2 = .32). The direct effect of social anxiety on body dysmorphic symptoms remained significant after controlling for appearance-RS (b = .09, 95% CI = .03–.15), suggesting appearance-RS partially mediated the relationship between social anxiety and symptoms. As shown in Table 3, the model results were similar when the avoidance factor of body dysmorphic symptoms was examined, rather than the total symptom score. However, when the threat monitoring factor of body dysmorphic symptoms was examined as the dependent variable, the results indicated full mediation of the association of social anxiety with threat monitoring via appearance-RS. The indirect effect of social anxiety on threat monitoring via appearance-RS was significant (b = .05, 95% CI = .04–.08, k2 = .26), whereas the direct effect was not significant after controlling for appearance-RS (b = .02, 95% CI = −.01 to .05). Reverse mediation was also tested. When appearancebased victimization was the dependent variable, the indirect Table 2 Results of regressing appearance-RS on social anxiety, and appearance-based victimization (N = 237).
.18** .59***
the proportion of the maximum possible indirect effect (Preacher & Kelley, 2011), and can be interpreted as small (.01), medium (.09), or large (.25). All tests were two-tailed, and the alpha level was set to .05.
.56***
Body dysmorphic symptoms
.05
Fig. 1. Mediational model with standardized regression coefficients of social anxiety and perceived appearance-related verbal victimization predicting body dysmorphic symptoms, mediated by appearance-RS. * p < .05; ** p < .01; *** p < .001.
Independent variables
B
SE (B)
t
ˇ
Age Gender Social anxiety Appearance-based victimization
0.00 2.15 .28 .21
.08 .86 .03 .08
−0.00 2.51 10.95 2.82
.00 .12* .59*** .15**
Note: R2 = .45, F(4, 232) = 46.44, p < .001. * p < .05. ** p < .01. *** p < .001.
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Table 3 Results of a mediation analysis regressing body dysmorphic symptoms on social anxiety, appearance-based victimization, and appearance-RS (N = 237). Independent variables
Body dysmorphic symptoms B
Step 1 Age Gender Social anxiety Appearance victimization Step 2 Age Gender Appearance-RS Social anxiety Appearance victimization
SE
t
R2 = 0.37, F(4, 232) = 34.63*** −0.10 0.09 −1.11 2.98 0.94 3.18 0.25 0.03 8.93 0.20 0.08 2.39 R2 = 0.17, F(1, 231) = 87.94*** −0.10 0.07 −1.30 1.74 0.81 2.16 0.57 0.06 9.38 0.09 0.03 3.03 0.07 0.07 1.05
Avoidance ˇ −0.06 0.17** 0.51*** 0.13* −0.06 0.10* 0.56*** 0.18** 0.05
B
Threat-monitoring SE
t
R2 = 0.37, F(4, 232) = 36.25*** −0.01 0.06 −0.21 2.17 0.64 3.42 0.17 0.12 9.19 0.15 0.06 2.74 2 R = 0.16, F(1, 231) = 81.10*** −0.01 0.05 −0.24 1.36 0.56 2.45 0.38 0.04 9.01 0.07 0.02 3.40 0.07 0.05 1.49
ˇ −0.01 0.17** 0.52*** 0.15** −0.01 0.11* 0.54*** 0.21** 0.07
B
SE
t
R2 = 0.23, F(4, 232) = 18.615*** −0.08 0.04 −2.24 0.81 0.41 1.98 0.08 0.01 6.20 0.04 0.04 1.12 2 R = 0.13, F(1, 231) = 47.62*** −0.08 0.03 −2.46 0.39 0.38 1.03 0.20 0.03 6.90 0.02 0.01 1.49 0.00 0.03 0.06
ˇ −0.13* 0.11* 0.39*** 0.07 −0.13* 0.06 0.48*** 0.11 0.00
Note: Final R2 = 0.55, F(5, 231) = 55.67, p < 0.001 for total body dysmorphic symptoms; R2 = 0.55, F(5, 231) = 55.23, p < 0.001 for avoidance; R2 = 0.37, F(5, 231) = 26.96, p < 0.001 for threat-monitoring. * p < .05. ** p < .01. *** p < .001.
association of body dysmorphic symptoms via appearance-RS was not significant (b = .06, 95% CI = −.01 to .14). When social anxiety was the dependent variable, the indirect association of body dysmorphic symptoms via appearance-RS was significant (b = .60, 95% CI = .41–.81, k2 = .27). The direct effect of body dysmorphic symptoms on social anxiety was also significant (b = .43, 95% CI = .15–.71), suggesting partial mediation. Discussion In the present study, social risks for body dysmorphic symptoms were examined in a non-clinical population. In particular, appearance-RS was examined as a mediator for the relationships of appearance-based verbal victimization and body dysmorphic symptoms, on the one hand, and social anxiety and body dysmorphic symptoms on the other hand. As predicted, both appearance-based victimization and social anxiety were associated with heightened symptoms. Moreover, appearance-RS was elevated for those with more symptoms. Of most importance, however, appearance-RS was found to fully mediate the relationship between perceived appearance-based victimization and body dysmorphic symptoms, and to partially mediate the relationship between social anxiety and body dysmorphic symptoms. Hence, the mediational hypotheses were generally supported. These findings suggest that a tendency to anxiously expect and readily perceive appearance-related social rejection may be an important mechanism in explaining why individuals who are teased in their adolescent years, or who have a predisposition towards general social anxiety, may exhibit heightened body dysmorphic symptoms. For example, individuals who are the victims of teasing about their appearance may develop a cognitive bias towards interpreting further social rejection, as well as the use of strategies to avoid further victimization and rejection such as social avoidance (Zimmer-Gembeck & Nesdale, 2013), or attempts to alter one’s appearance with grooming, camouflaging, or cosmetic surgery (Calogero et al., 2010; Park, Calogero, Harwin, & DiRaddo, 2009; Park et al., 2010; Park & Harwin, 2010). They may also be more likely to react with aggression, which has been found to be one reaction to rejection common among young people who have elevated rejection sensitivity (Zimmer-Gembeck & Nesdale, 2013). These findings support and extend previous research by Fang et al. (2011), who found that personal-RS partially mediated the relationship between social anxiety and BDD symptoms. In the current study, the relationship between social anxiety and threat monitoring symptoms was fully mediated by appearanceRS, whereas the relationship between social anxiety and avoidance
symptoms was partially mediated. This could suggest that a general fear of negative evaluation by others may still be uniquely important in predicting avoidance behaviours in individuals with elevated body dysmorphic symptoms. Consequently, there are likely to be multiple pathways from social anxiety to body dysmorphic symptoms. A combination of social and cultural influences may play an important role in explaining the relationship, such as overly critical parenting, exposure to media, and peer pressure. Further, as the reverse association was also significant, results support that a reciprocal relationship between body dysmorphic symptoms and social anxiety via appearance-RS could occur. Given there are only a small number of studies that have examined the efficacy of treatments for BDD (see Wilhelm, Phillips, & Steketee, 2013), a greater understanding of the underlying mechanisms of the disorder will be important in the development of successful treatments. To the authors’ knowledge, this study is the first to demonstrate the role of appearance-RS as a mechanism between proposed social risk factors and body dysmorphic symptoms. Thus, appearance-RS may be important to consider when conceptualizing patients’ body dysmorphic concerns in clinical settings, particularly for individuals who have early experiences of appearance-related victimization. Restructuring of maladaptive beliefs and cognitions about the likelihood of being rejected by others based on one’s appearance may be a useful component of cognitive therapy for body dysmorphic concerns. Results of this study may also be relevant for behavioural components of CBT for body dysmorphic concerns (Wilhelm et al., 2013). For example, it may be important for exposure hierarchies to incorporate situations that are avoided due to a fear of appearance-based rejection. All findings from the current study should be considered in light of the fact that the participants were a non-clinical sample of university students and clinical interviews for social anxiety and body dysmorphic disorder were not conducted. Therefore, the findings of this study may not generalize to clinical populations. However, it is known that body dysmorphic symptoms can be common in this age group and within university students (Bartsch, 2007), making it an appropriate population for this research. Another limitation of the current study is that personal-RS was not controlled for in the mediation analysis, to assess whether appearance-RS accounted for any additional variance to the model tested in Fang et al. (2011). Further, other factors that might predict body dysmorphic concerns were not included in this study, such as genetic prediction (Monzani et al., 2012), and childhood history of abuse (Didie, Torolani, Pope, Menard, Fay, & Phillips, 2006). This study’s cross-sectional design also limits conclusions about the direction of effects. This limitation highlights the need for
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longitudinal studies to determine whether appearance-based victimization and social anxiety indeed precede the onset of body dysmorphic symptoms. Finally, appearance-based victimization was self-reported, making it possible that individuals with a greater sensitivity to rejection were more likely to retrospectively perceive greater levels of verbal victimization about their appearance. To overcome potential biases in self-report, longitudinal research should include other reports of victimization and rejection sensitivity by peers or parents (Zimmer-Gembeck, Hunter, & Pronk, 2007; Zimmer-Gembeck, Nesdale, McGregor, Mastro, Goodwin, & Downey, 2013; ZimmerGembeck, Trevaskis, Nesdale, & Downey, 2013). Overall, this study has extended the current literature on the important correlates of BDD, a poorly understood mental health disorder that, if left untreated, can lead to severe functional impairment and high risk of suicide. It is recommended that future studies expand the model tested here to investigate the usefulness of more comprehensive cognitive behavioural models of BDD (e.g., Buhlmann & Wilhelm, 2004; Neziroglu et al., 2008), to explain when and why social anxiety and adverse childhood experiences contribute to the development of BDD. Such an understanding will direct advances in treatments, and, in turn, improve the quality of life of individuals with this profoundly debilitating disorder. References American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing. Anson, M., Veale, D., & de Silva, P. (2012). Social-evaluative versus self-evaluative appearance concerns in body dysmorphic disorder. Behaviour Research and Therapy, 50, 753–760. http://dx.doi.org/10.1016/j.brat.2012.09.003 Bartsch, D. (2007). Prevalence of body dysmorphic disorder symptoms and associated clinical features among Australian university students. Clinical Psychologist, 11, 16–23. http://dx.doi.org/10.1080/13284200601178532 Buhlmann, U., Cooke, L. M., Fama, J. M., & Wilhelm, S. (2007). Perceived teasing experiences in body dysmorphic disorder. Body Image, 4, 381–385. http://dx.doi. org/10.1016/j.bodyim.2007.06.004 Buhlmann, U., Glaesmer, H., Mewes, R., Fama, J. M., Wilhelm, S., Brahler, E., & Rief, W. (2010). Updates on the prevalence of body dysmorphic disorder: A populationbased survey. Psychiatry Research, 178, 171–175. http://dx.doi.org/10. 1016/j.psychres.2009.05.002 Buhlmann, U., & Wilhelm, S. (2004). Cognitive factors in body dysmorphic disorder. Psychiatric Annals, 34, 922–926. Retrieved from http://www.proquest.co.uk/ Buhlmann, U., Wilhelm, S., Glaesmer, H., Mewes, R., Brähler, E., & Rief, W. (2011). Perceived appearance-related teasing in body dysmorphic disorder: A population-based survey. International Journal of Cognitive Therapy, 4, 342–348. http://dx.doi.org/10.1521/ijct.2011.4.4.342 Calogero, R. M., Park, L. E., Rahemtulla, Z. K., & Williams, K. C. D. (2010). Predicting excessive body image concerns among British university students: The unique role of appearance-based rejection sensitivity. Body Image, 7, 78–81. http://dx.doi.org/10.1016/j.bodyim.2009.09.005 Coles, M. E., Phillips, K. A., Menard, W., Pagano, M., Fay, C., Weisberg, R. B., & Stout, R. L. (2006). Body dysmorphic disorder and social phobia: Cross-sectional and prospective data. Depression and Anxiety, 23, 26–33. http://dx.doi.org/10. 1002/da.20132 Didie, E. R., Torolani, C. C., Pope, C. G., Menard, W., Fay, C., & Phillips, K. A. (2006). Childhood abuse and neglect in body dysmorphic disorder. Child Abuse and Neglect, 30, 1105–1115. http://dx.doi.org/10.1016/j.chiabu.2006.03.007 Fang, A., Asnaani, A., Gutner, C., Cook, C., Wilhelm, S., & Hofmann, S. G. (2011). Rejection sensitivity mediates the relationship between social anxiety and body dysmorphic disorder. Journal of Anxiety Disorders, 25, 946–949. http://dx.doi.org/10.1016/j.janxdis.2011.06.001 Feldman, S., & Downey, G. (1994). Rejection sensitivity as a mediator of the impact of childhood exposure to family violence on adult attachment behavior. Development and Psychopathology, 6, 231–247. http://dx.doi.org/10. 1017/S0954579400005976 Hayes, A. F. (2013). An introduction to mediation, moderation, and conditional process analysis: A regression-based approach. New York, NY: Guilford Press. Inderbitzen-Nolan, H. M., & Walters, K. S. (2000). Social Anxiety Scale for Adolescents: Normative data and further evidence of construct validity. Journal of Abnormal Child Psychology, 29, 360–371. http://dx.doi.org/10. 1207/S15374424JCCP2903 7 Kelly, M. A., Didie, E. R., & Phillips, K. A. (2014). Personal and appearance-based rejection sensitivity in body dysmorphic disorder. Body Image, 11, 260–265. http://dx.doi.org/10.1016/j.bodyim.2014.03.004
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Visible versus non-visible rejection: Consequences of appearance-based rejection sensitivity. Journal of Research in Personality, 44, 128–132. http://dx.doi.org/10.1016/j.jrp.2009.10.001 Phillips, K. A., & Diaz, S. F. (1997). Gender differences in body dysmorphic disorder. The Journal of Nervous and Mental Disease, 185, 570–577. Retrieved from http://journals.lww.com/ Phillips, K. A., & Menard, W. (2006). Suicidality in body dysmorphic disorder: A prospective study. The American Journal of Psychiatry, 163, 1280–1282. http://dx.doi.org/10.1176/appi.ajp.163.7.1280 Phillips, K. A., Menard, W., Fay, C., & Weisberg, R. (2005). Demographic characteristics, phenomenology, comorbidity, and family history in 200 individuals with body dysmorphic disorder. Psychosomatics, 46, 317–325. http://dx.doi.org/10. 1176/appi.psy.46.4.317 Preacher, K. J., & Kelley, K. (2011). Effect size measures for mediation models: Quantitative strategies for communicating indirect effects. Psychological Methods, 16, 93–115. http://dx.doi.org/10.1037/a0022658.supp Rief, W., Buhlmann, U., Wilhelm, S., Borkenhagen, A., & Brähler, E. (2006). The prevalence of body dysmorphic disorder: A population-based survey. Psychological Medicine, 36, 877–885. http://dx.doi.org/10.1017/S0033291706007264 Thompson, C. M., & Durrani, A. J. (2007). An increasing need for early detection of body dysmorphic disorder by all specialties. Journal of the Royal Society of Medicine, 100, 61–62. Retrieved from http://jrs.sagepub.com/ Thompson, J. K., Cattarin, J., Fowler, B., & Fisher, E. (1995). The Perception of Teasing Scale (POTS): A revision and extension of the Physical Appearance Related Teasing Scale (PARTS). Journal of Personality Assessment, 65, 146–157. http://dx.doi.org/10.1207/s15327752jpa6501 11 Veale, D., Eshkevari, E., Kanakam, N., Ellison, N., Costa, A., & Werner, T. (2013). The Appearance Anxiety Inventory: Validation of a process measure in the treatment of body dysmorphic disorder. Behavioural and Cognitive Psychotherapy, http://dx.doi.org/10.1017/S1352465813000556 (Advance online publication) Wilhelm, S., & Neziroglu, F. (2002). Cognitive theory of body dysmorphic disorder. In R. O. Frost & G. Steketee (Eds.), Cognitive approaches to obsessions and compulsions: Theory, assessment and treatment (pp. 203–214). Oxford, England: Elsevier Press. Wilhelm, S., Phillips, K. A., & Steketee, G. (2013). Cognitive-behavioral therapy for body dysmorphic disorder: A treatment manual. New York, NY: The Guilford Press. Zimmer-Gembeck, M. J., Hunter, T., & Pronk, R. E. (2007). A model of behaviours, peer relations and depression: Perceived social acceptance as a mediator and the divergence of perceptions. Journal of Social and Clinical Psychology, 26, 273–285. http://dx.doi.org/10.1521/jscp.2007.26.3.273 Zimmer-Gembeck, M. J., & Nesdale, D. (2013). Anxious and angry rejection sensitivity, social withdrawal, and retribution in high and low ambiguous situations. Journal of Personality, 81, 29–38. http://dx.doi.org/10. 1111/j.1467-6494.2012.00792.x Zimmer-Gembeck, M. J., Nesdale, D., McGregor, L., Mastro, S., Goodwin, B., & Downey, G. (2013). Comparing reports of peer rejection: Associations with rejection sensitivity, victimization, aggression, and friendship. Journal of Adolescence, 36, 1237–1246. http://dx.doi.org/10.1016/j.adolescence.2013.10.002 Zimmer-Gembeck, M. J., Trevaskis, S., Nesdale, D., & Downey, G. (2013). Relational victimization, loneliness and depressive symptoms: Indirect associations via self and peer reports of rejection sensitivity. Journal of Youth and Adolescence, 43, 568–582. http://dx.doi.org/10.1007/s10964-013-9993-6 Zimmerman, M., & Mattia, J. I. (1998). Body dysmorphic disorder in psychiatric outpatients: Recognition, prevalence, comorbidity, demographics, and clinical correlates. 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Victimization, social anxiety, and body dysmorphic concerns: Appearance-based rejection sensitivity as a mediator Cassie H. Lavell ∗ , Melanie J. Zimmer-Gembeck, Lara J. Farrell, Haley Webb School of Applied Psychology & Griffith Health Institute, Griffith University, Gold Coast Campus, Australia
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Article history: Received 2 January 2014 Received in revised form 15 June 2014 Accepted 17 June 2014 Keywords: Body dysmorphic disorder Social anxiety Appearance-based victimization Appearance-based rejection sensitivity
Body dysmorphic disorder (BDD) is characterized by extreme preoccupation with perceived deficits in physical appearance, and sufferers experience severe impairment in functioning. Previous research has indicated that individuals with BDD are high in social anxiety, and often report being the victims of appearance-based teasing. However, there is little research into the possible mechanisms that might explain these relationships. The current study examined appearance-based rejection sensitivity as a mediator between perceived appearance-based victimization, social anxiety, and body dysmorphic symptoms in a sample of 237 Australian undergraduate psychology students. Appearance-based rejection sensitivity fully mediated the relationship between appearance-based victimization and body dysmorphic symptoms, and partially mediated the relationship between social anxiety and body dysmorphic symptoms. Findings suggest that individuals high in social anxiety or those who have a history of more appearance-based victimization may have a bias towards interpreting further appearance-based rejection, which may contribute to extreme appearance concerns such as BDD. © 2014 Elsevier Ltd. All rights reserved.
Introduction Body dysmorphic disorder (BDD) is characterized by preoccupation with perceived deficits in physical appearance, which are viewed as unattractive, abnormal or deformed (American Psychiatric Association, 2013). Preoccupation is a critical element of BDD and includes persistent thoughts about the perceived defect, but also involves behaviours that can interfere with day-to-day living, such as frequent attempts to camouflage or hide perceived defects, a compulsion to check appearance in mirrors, and excessive reassurance seeking from others (Phillips, Menard, Fay, & Weisberg, 2005). Very little is known about the aetiology or developmental pathways of BDD, but this disorder has drawn increasing research attention in recent years, partly due to its increasing presentation across specialist settings, outside of mental health care. For example, up to 12% of patients seen by dermatologists, and up to 15% of patients seeking cosmetic surgery meet the criteria for BDD (Thompson & Durrani, 2007). Furthermore, the seriousness of BDD is now widely accepted with evidence that this disorder is
∗ Corresponding author at: Griffith Health Institute, School of Applied Psychology, Griffith University, Gold Coast Campus, Queensland 4222, Australia. Tel.: +61 432611172. E-mail address: cassie.lavell@griffithuni.edu.au (C.H. Lavell). http://dx.doi.org/10.1016/j.bodyim.2014.06.008 1740-1445/© 2014 Elsevier Ltd. All rights reserved.
associated with profound impairment for sufferers, including high rates of suicidal ideation and attempts (Phillips & Menard, 2006). Thus, cognitive behavioural models have emerged that identify how symptoms may develop and be maintained over time. For example, Veale and colleagues (e.g., Neziroglu, Khemlani-Patel, & Veale, 2008) proposed a model that describes the maintenance of BDD symptoms via internal processes such as excessive selffocused attention, negative appraisals of body image, and rumination. It has also been proposed that predisposing factors, such as fear of negative evaluation and adverse social experiences (e.g., victimization, teasing, and abuse) lead to distorted processing of emotional and social input (Buhlmann & Wilhelm, 2004; Wilhelm & Neziroglu, 2002). These distortions result in high levels of distress and, in an attempt to neutralize these negative feelings, individuals with BDD perform ritualistic behaviours, seek reassurance, and avoid situations that trigger discomfort or anxiety. In a counterproductive manner, these safety and avoidance behaviours serve to maintain the disorder through temporary relief from negative emotions (Buhlmann & Wilhelm, 2004; Wilhelm & Neziroglu, 2002). Thus, this model suggests a pathway from early victimization and fear of negative evaluation (often measured as social anxiety symptoms) to BDD that occurs via appearance-related concerns and obsessions. Such appearance-related concerns have recently been described in research on appearance-based rejection sensitivity (appearance-RS). However, no previous research has tested such a model incorporating the roles of both social anxiety and
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appearance-based victimization in BDD, while also testing whether these associations are fully or partly mediated by appearance-RS. The purpose of this study was to investigate this mediational model in a sample of undergraduate university students. Appearance-based Victimization and Social Anxiety as Correlates of BDD Appearance-based victimization. In support of the view that there are social risks underlying the cognitions that mark BDD, BDD patients have been found to report being the victims of teasing or bullying in school, especially as related to their appearance. For example, in an investigation of spontaneously occurring images and early memories, Osman, Cooper, Hackmann, and Veale (2004) found that BDD patients’ memories typically involved themes of teasing and bullying about their appearance in school. Moreover, compared to controls, BDD patients report significantly greater perceived appearance-related verbal victimization from their childhood and adolescence (Buhlmann, Cooke, Fama, & Wilhelm, 2007), and recall these experiences as more traumatic (Buhlmann, Wilhelm, Glaesmer, Mewes, Brähler, & Rief, 2011). Social anxiety. Another risk factor for BDD appears to be social anxiety, especially fear of negative evaluation by others (Anson, Veale, & de Silva, 2012). Prevalence rates of social phobia in individuals with BDD tend to be high, ranging from 12% to 69% (Phillips & Diaz, 1997; Zimmerman & Mattia, 1998). Moreover, in studies of individuals with comorbid social phobia and BDD, the onset of social phobia tends to precede the onset of BDD (e.g., Coles et al., 2006). This provides further support for the risk stage of cognitive behavioural models, and could suggest social anxiety contributes to the development of BDD. However, despite the evidence that victimization, especially related to appearance, and social anxiety are important risk factors for BDD, there is little research into the possible mechanisms that might explain these relationships. Appearance-based Rejection Sensitivity as a Mediator and Aims of the Present Study Appearance-RS refers to the tendency to anxiously expect, readily perceive, and overreact to signs of rejection based on one’s physical appearance (Park, 2007). In samples of university students in the United Kingdom (Calogero, Park, Rahemtulla, & Williams, 2010) and United States (Park, Calogero, Young, & DiRaddo, 2010), appearance-RS has been found to be associated with greater BDD symptoms, suggesting concerns about appearance-based rejection may be important in understanding the development of BDD. Appearance-RS is modelled after Feldman and Downey’s (1994) construct of personal rejection sensitivity (personal-RS), which partially mediated the relationship between social anxiety and BDD symptoms in study of 218 undergraduate university students by Fang, Asnaani, Gutner, Cook, Wilhelm, and Hofmann (2011). In light of research that suggests appearance-RS may account for more unique variance in BDD severity than personal-RS (Kelly, Didie, & Phillips, 2014), it is possible that appearance-RS may also be an underlying mechanism in the relationship between social anxiety and BDD, and may account for more variance. Further, Feldman and Downey (1994) proposed that rejection sensitivity serves as a mediator between early experiences and processing of current information. Thus, it is possible that early experiences of appearance-based victimization may contribute to expectations of further rejection, which, in turn, might explain symptoms of BDD such as social avoidance or attempts to “fix” or improve one’s appearance (e.g., cosmetic surgery, excessive grooming, camouflaging) in order to prevent future rejection. Therefore, we examined whether appearance-RS was a potential mediator in explaining why appearance-based victimization
and social anxiety are associated with heightened body dysmorphic symptoms. This study extends the research of Fang et al. (2011) by incorporating appearance-based victimization into the model, and testing appearance-RS as an alternative mediator to personal-RS. The model was tested with a university sample, given the high rates of body concerns among this group (Bartsch, 2007). Specifically, it was hypothesized that (1) appearance-RS would mediate the relationship between social anxiety and body dysmorphic symptoms, and that (2) appearance-RS would mediate the relationship between perceived appearance-based victimization and body dysmorphic symptoms. Given the slightly higher prevalence of BDD in younger adults relative to older adults, and higher prevalence in women relative to men (Buhlmann et al., 2010; Koran, Abujaoude, Large, & Serpe, 2008; Rief, Buhlmann, Wilhelm, Borkenhagen, & Brähler, 2006), age and gender were included as covariates in the model. Method Participants The participants were 237 Australian first-year university students (74% female) aged 17–42 years (Mage = 21.13 years, SD = 4.86). The majority of participants were Australian-born (79%), with English as their first spoken language (91%). Measures Body dysmorphic symptoms. The 10-item Appearance Anxiety Inventory (AAI; Veale, Eshkevari, Kanakam, Ellison, Costa, & Werner, 2013) was used to measure body dysmorphic symptoms. The scale has two factors: (1) avoidance, which reflects camouflaging and avoidance behaviours, and (2) threat monitoring, which reflects checking, rumination, and reassurance seeking. Participants rated each item on a 5-point scale (0 = Not at all, 4 = All the time). Total scores were created by summing the items. While the AAI is a relatively new measure, Veale et al. (2013) found that the scale discriminated between individuals with a diagnosis of BDD and individuals without a diagnosis, and had good convergent validity (r = .55) with the Yale-Brown Obsessive Compulsive Scale modified for BDD (Veale et al., 2013). Cronbach’s ˛ in the current study was .90 for total symptoms, .89 for avoidance, and .73 for threat monitoring. Appearance-based rejection sensitivity. The 15-item Appearance-based Rejection Sensitivity Scale (Park, 2007) was used to measure participants’ appearance-based expectations of rejection. Participants read 15 scenarios and indicated how concerned or anxious they would feel about being rejected on a 6-point scale (1 = Very unconcerned, 6 = Very concerned), and how much they would expect rejection (1 = Very unlikely, 6 = Very likely). Total scores reflect the mean of all scenarios’ anxious concern score multiplied by expectation score. In the present study, Cronbach’s ˛ was .96. Social anxiety. The 18-item Social Anxiety Scale for Adolescents (La Greca & Lopez, 1998) was used to assess fear of negative evaluation, social avoidance, and distress in social situations. Items were rated on a 5-point scale (1 = Not true, 5 = Very true) and items were summed to form total scores. This measure has demonstrated convergent validity with other social anxiety measures and discriminant validity with measures of depression (Inderbitzen-Nolan & Walters, 2000). In the present study, Cronbach’s ˛ was .95. Appearance-based verbal victimization. A modified version of the Perceptions of Teasing Scale (Thompson, Cattarin, Fowler, & Fisher, 1995) was used to measure the frequency of perceived verbal victimization experienced between ages 5 and 16 years. The
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Table 1 Means, standard deviations, and bivariate correlations between all measures. Variable
M
SD
1
1. Body dysmorphic symptoms 2. Avoidance 3. Threat monitoring 4. Social anxiety 5. Appearance-based victimization 6. Appearance-RS
11.98 7.10 4.97 46.34 12.84 13.35
7.82 5.43 3.14 16.03 5.31 7.65
– .96 .87 .58 .29 .71
2
3
4
5
– .70 .58 .31 .71
– .46 .19 .58
– .32 .64
– .33
Note: All ps < .01.
original measure had 11 items consisting of two subscales: weightrelated teasing (6 items) and competence-related teasing (5 items). In the current study, the authors modified weight-related items to assess appearance-related victimization (e.g., “People made fun of you because you were heavy” was changed to “People made fun of you because of your appearance”). The frequency of each item was rated on a 5-point scale (1 = Never, 5 = Very often). The scale also assesses victimization distress. However, only items related to the frequency of appearance-based victimization were included in the analyses. Summing the six appearance-related items formed the total scores. In the present study, Cronbach’s ˛ was .85. Procedure Following ethical approval by the university Human Research Ethics Committee, a 30-min online questionnaire was administered to first-year psychology students attending university on the Gold Coast, Australia. The study was advertised via a university webpage that listed various research projects recruiting first-year student participants. All students received 0.5% course credit for their participation. An information page was provided on the first page of the questionnaire, including a description of the study, the risks and benefits, the opportunity for debriefing, confidentiality, and informed consent. Statistical Analyses Distributions and unusual scores were examined via scatterplots, studentized residuals, leverage scores, and Cook’s D. No individual cases were deleted or transformed. Pearson correlation coefficients were calculated to determine the associations among variables. The mediational model was tested using the Process macro (Hayes, 2013), with social anxiety and appearance-based verbal victimization as independent variables, body dysmorphic symptoms as the dependent variable, and appearance-RS as the mediator (see Fig. 1). Age and gender were entered as covariates. The same model was also tested with the two factors of the AAI, avoidance and threat monitoring, as dependent variables. For fully mediated effects to occur, direct pathways from the independent variables to the dependent variable should be non-significant after controlling for the mediator. Kappa squared (k2 ) effect size statistics were calculated for each of the indirect effects. k2 represents
Social anxiety
.32*** .15* Appearance-based victimization
Appearance-based rejection sensitivity
Results Means, standard deviations, and bivariate correlations among all variables are presented in Table 1. All variables met the criteria for mediation analysis with significant associations in the expected directions, all ps < .001. As shown in Table 2, social anxiety and appearance-based victimization were both uniquely associated with appearance-RS in a regression model. Appearance-RS was, in turn, significantly associated with body dysmorphic symptoms after controlling for the two independent variables (Table 3). Bootstrapped 95% confidence intervals (95% CI) showed that the indirect effect of appearance-based victimization on body dysmorphic symptoms via appearance-RS was significant (b = .12, 95% CI = .03–.23, k2 = .09). The direct effect of appearance-based victimization on body dysmorphic symptoms was not significant after controlling for appearance-RS (b = .07, 95% CI = −.07 to .21), suggesting full mediation of the association between victimization and symptoms via appearance-RS. The indirect pathway from social anxiety to body dysmorphic symptoms via appearance-RS was also significant (b = .16, 95% CI = .11–.21, k2 = .32). The direct effect of social anxiety on body dysmorphic symptoms remained significant after controlling for appearance-RS (b = .09, 95% CI = .03–.15), suggesting appearance-RS partially mediated the relationship between social anxiety and symptoms. As shown in Table 3, the model results were similar when the avoidance factor of body dysmorphic symptoms was examined, rather than the total symptom score. However, when the threat monitoring factor of body dysmorphic symptoms was examined as the dependent variable, the results indicated full mediation of the association of social anxiety with threat monitoring via appearance-RS. The indirect effect of social anxiety on threat monitoring via appearance-RS was significant (b = .05, 95% CI = .04–.08, k2 = .26), whereas the direct effect was not significant after controlling for appearance-RS (b = .02, 95% CI = −.01 to .05). Reverse mediation was also tested. When appearancebased victimization was the dependent variable, the indirect Table 2 Results of regressing appearance-RS on social anxiety, and appearance-based victimization (N = 237).
.18** .59***
the proportion of the maximum possible indirect effect (Preacher & Kelley, 2011), and can be interpreted as small (.01), medium (.09), or large (.25). All tests were two-tailed, and the alpha level was set to .05.
.56***
Body dysmorphic symptoms
.05
Fig. 1. Mediational model with standardized regression coefficients of social anxiety and perceived appearance-related verbal victimization predicting body dysmorphic symptoms, mediated by appearance-RS. * p < .05; ** p < .01; *** p < .001.
Independent variables
B
SE (B)
t
ˇ
Age Gender Social anxiety Appearance-based victimization
0.00 2.15 .28 .21
.08 .86 .03 .08
−0.00 2.51 10.95 2.82
.00 .12* .59*** .15**
Note: R2 = .45, F(4, 232) = 46.44, p < .001. * p < .05. ** p < .01. *** p < .001.
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Table 3 Results of a mediation analysis regressing body dysmorphic symptoms on social anxiety, appearance-based victimization, and appearance-RS (N = 237). Independent variables
Body dysmorphic symptoms B
Step 1 Age Gender Social anxiety Appearance victimization Step 2 Age Gender Appearance-RS Social anxiety Appearance victimization
SE
t
R2 = 0.37, F(4, 232) = 34.63*** −0.10 0.09 −1.11 2.98 0.94 3.18 0.25 0.03 8.93 0.20 0.08 2.39 R2 = 0.17, F(1, 231) = 87.94*** −0.10 0.07 −1.30 1.74 0.81 2.16 0.57 0.06 9.38 0.09 0.03 3.03 0.07 0.07 1.05
Avoidance ˇ −0.06 0.17** 0.51*** 0.13* −0.06 0.10* 0.56*** 0.18** 0.05
B
Threat-monitoring SE
t
R2 = 0.37, F(4, 232) = 36.25*** −0.01 0.06 −0.21 2.17 0.64 3.42 0.17 0.12 9.19 0.15 0.06 2.74 2 R = 0.16, F(1, 231) = 81.10*** −0.01 0.05 −0.24 1.36 0.56 2.45 0.38 0.04 9.01 0.07 0.02 3.40 0.07 0.05 1.49
ˇ −0.01 0.17** 0.52*** 0.15** −0.01 0.11* 0.54*** 0.21** 0.07
B
SE
t
R2 = 0.23, F(4, 232) = 18.615*** −0.08 0.04 −2.24 0.81 0.41 1.98 0.08 0.01 6.20 0.04 0.04 1.12 2 R = 0.13, F(1, 231) = 47.62*** −0.08 0.03 −2.46 0.39 0.38 1.03 0.20 0.03 6.90 0.02 0.01 1.49 0.00 0.03 0.06
ˇ −0.13* 0.11* 0.39*** 0.07 −0.13* 0.06 0.48*** 0.11 0.00
Note: Final R2 = 0.55, F(5, 231) = 55.67, p < 0.001 for total body dysmorphic symptoms; R2 = 0.55, F(5, 231) = 55.23, p < 0.001 for avoidance; R2 = 0.37, F(5, 231) = 26.96, p < 0.001 for threat-monitoring. * p < .05. ** p < .01. *** p < .001.
association of body dysmorphic symptoms via appearance-RS was not significant (b = .06, 95% CI = −.01 to .14). When social anxiety was the dependent variable, the indirect association of body dysmorphic symptoms via appearance-RS was significant (b = .60, 95% CI = .41–.81, k2 = .27). The direct effect of body dysmorphic symptoms on social anxiety was also significant (b = .43, 95% CI = .15–.71), suggesting partial mediation. Discussion In the present study, social risks for body dysmorphic symptoms were examined in a non-clinical population. In particular, appearance-RS was examined as a mediator for the relationships of appearance-based verbal victimization and body dysmorphic symptoms, on the one hand, and social anxiety and body dysmorphic symptoms on the other hand. As predicted, both appearance-based victimization and social anxiety were associated with heightened symptoms. Moreover, appearance-RS was elevated for those with more symptoms. Of most importance, however, appearance-RS was found to fully mediate the relationship between perceived appearance-based victimization and body dysmorphic symptoms, and to partially mediate the relationship between social anxiety and body dysmorphic symptoms. Hence, the mediational hypotheses were generally supported. These findings suggest that a tendency to anxiously expect and readily perceive appearance-related social rejection may be an important mechanism in explaining why individuals who are teased in their adolescent years, or who have a predisposition towards general social anxiety, may exhibit heightened body dysmorphic symptoms. For example, individuals who are the victims of teasing about their appearance may develop a cognitive bias towards interpreting further social rejection, as well as the use of strategies to avoid further victimization and rejection such as social avoidance (Zimmer-Gembeck & Nesdale, 2013), or attempts to alter one’s appearance with grooming, camouflaging, or cosmetic surgery (Calogero et al., 2010; Park, Calogero, Harwin, & DiRaddo, 2009; Park et al., 2010; Park & Harwin, 2010). They may also be more likely to react with aggression, which has been found to be one reaction to rejection common among young people who have elevated rejection sensitivity (Zimmer-Gembeck & Nesdale, 2013). These findings support and extend previous research by Fang et al. (2011), who found that personal-RS partially mediated the relationship between social anxiety and BDD symptoms. In the current study, the relationship between social anxiety and threat monitoring symptoms was fully mediated by appearanceRS, whereas the relationship between social anxiety and avoidance
symptoms was partially mediated. This could suggest that a general fear of negative evaluation by others may still be uniquely important in predicting avoidance behaviours in individuals with elevated body dysmorphic symptoms. Consequently, there are likely to be multiple pathways from social anxiety to body dysmorphic symptoms. A combination of social and cultural influences may play an important role in explaining the relationship, such as overly critical parenting, exposure to media, and peer pressure. Further, as the reverse association was also significant, results support that a reciprocal relationship between body dysmorphic symptoms and social anxiety via appearance-RS could occur. Given there are only a small number of studies that have examined the efficacy of treatments for BDD (see Wilhelm, Phillips, & Steketee, 2013), a greater understanding of the underlying mechanisms of the disorder will be important in the development of successful treatments. To the authors’ knowledge, this study is the first to demonstrate the role of appearance-RS as a mechanism between proposed social risk factors and body dysmorphic symptoms. Thus, appearance-RS may be important to consider when conceptualizing patients’ body dysmorphic concerns in clinical settings, particularly for individuals who have early experiences of appearance-related victimization. Restructuring of maladaptive beliefs and cognitions about the likelihood of being rejected by others based on one’s appearance may be a useful component of cognitive therapy for body dysmorphic concerns. Results of this study may also be relevant for behavioural components of CBT for body dysmorphic concerns (Wilhelm et al., 2013). For example, it may be important for exposure hierarchies to incorporate situations that are avoided due to a fear of appearance-based rejection. All findings from the current study should be considered in light of the fact that the participants were a non-clinical sample of university students and clinical interviews for social anxiety and body dysmorphic disorder were not conducted. Therefore, the findings of this study may not generalize to clinical populations. However, it is known that body dysmorphic symptoms can be common in this age group and within university students (Bartsch, 2007), making it an appropriate population for this research. Another limitation of the current study is that personal-RS was not controlled for in the mediation analysis, to assess whether appearance-RS accounted for any additional variance to the model tested in Fang et al. (2011). Further, other factors that might predict body dysmorphic concerns were not included in this study, such as genetic prediction (Monzani et al., 2012), and childhood history of abuse (Didie, Torolani, Pope, Menard, Fay, & Phillips, 2006). This study’s cross-sectional design also limits conclusions about the direction of effects. This limitation highlights the need for
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longitudinal studies to determine whether appearance-based victimization and social anxiety indeed precede the onset of body dysmorphic symptoms. Finally, appearance-based victimization was self-reported, making it possible that individuals with a greater sensitivity to rejection were more likely to retrospectively perceive greater levels of verbal victimization about their appearance. To overcome potential biases in self-report, longitudinal research should include other reports of victimization and rejection sensitivity by peers or parents (Zimmer-Gembeck, Hunter, & Pronk, 2007; Zimmer-Gembeck, Nesdale, McGregor, Mastro, Goodwin, & Downey, 2013; ZimmerGembeck, Trevaskis, Nesdale, & Downey, 2013). Overall, this study has extended the current literature on the important correlates of BDD, a poorly understood mental health disorder that, if left untreated, can lead to severe functional impairment and high risk of suicide. It is recommended that future studies expand the model tested here to investigate the usefulness of more comprehensive cognitive behavioural models of BDD (e.g., Buhlmann & Wilhelm, 2004; Neziroglu et al., 2008), to explain when and why social anxiety and adverse childhood experiences contribute to the development of BDD. Such an understanding will direct advances in treatments, and, in turn, improve the quality of life of individuals with this profoundly debilitating disorder. References American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing. Anson, M., Veale, D., & de Silva, P. (2012). Social-evaluative versus self-evaluative appearance concerns in body dysmorphic disorder. Behaviour Research and Therapy, 50, 753–760. http://dx.doi.org/10.1016/j.brat.2012.09.003 Bartsch, D. (2007). Prevalence of body dysmorphic disorder symptoms and associated clinical features among Australian university students. Clinical Psychologist, 11, 16–23. http://dx.doi.org/10.1080/13284200601178532 Buhlmann, U., Cooke, L. M., Fama, J. M., & Wilhelm, S. (2007). Perceived teasing experiences in body dysmorphic disorder. Body Image, 4, 381–385. http://dx.doi. org/10.1016/j.bodyim.2007.06.004 Buhlmann, U., Glaesmer, H., Mewes, R., Fama, J. M., Wilhelm, S., Brahler, E., & Rief, W. (2010). Updates on the prevalence of body dysmorphic disorder: A populationbased survey. Psychiatry Research, 178, 171–175. http://dx.doi.org/10. 1016/j.psychres.2009.05.002 Buhlmann, U., & Wilhelm, S. (2004). Cognitive factors in body dysmorphic disorder. Psychiatric Annals, 34, 922–926. Retrieved from http://www.proquest.co.uk/ Buhlmann, U., Wilhelm, S., Glaesmer, H., Mewes, R., Brähler, E., & Rief, W. (2011). Perceived appearance-related teasing in body dysmorphic disorder: A population-based survey. International Journal of Cognitive Therapy, 4, 342–348. http://dx.doi.org/10.1521/ijct.2011.4.4.342 Calogero, R. M., Park, L. E., Rahemtulla, Z. K., & Williams, K. C. D. (2010). Predicting excessive body image concerns among British university students: The unique role of appearance-based rejection sensitivity. Body Image, 7, 78–81. http://dx.doi.org/10.1016/j.bodyim.2009.09.005 Coles, M. E., Phillips, K. A., Menard, W., Pagano, M., Fay, C., Weisberg, R. B., & Stout, R. L. (2006). Body dysmorphic disorder and social phobia: Cross-sectional and prospective data. Depression and Anxiety, 23, 26–33. http://dx.doi.org/10. 1002/da.20132 Didie, E. R., Torolani, C. C., Pope, C. G., Menard, W., Fay, C., & Phillips, K. A. (2006). Childhood abuse and neglect in body dysmorphic disorder. Child Abuse and Neglect, 30, 1105–1115. http://dx.doi.org/10.1016/j.chiabu.2006.03.007 Fang, A., Asnaani, A., Gutner, C., Cook, C., Wilhelm, S., & Hofmann, S. G. (2011). Rejection sensitivity mediates the relationship between social anxiety and body dysmorphic disorder. Journal of Anxiety Disorders, 25, 946–949. http://dx.doi.org/10.1016/j.janxdis.2011.06.001 Feldman, S., & Downey, G. (1994). Rejection sensitivity as a mediator of the impact of childhood exposure to family violence on adult attachment behavior. Development and Psychopathology, 6, 231–247. http://dx.doi.org/10. 1017/S0954579400005976 Hayes, A. F. (2013). An introduction to mediation, moderation, and conditional process analysis: A regression-based approach. New York, NY: Guilford Press. Inderbitzen-Nolan, H. M., & Walters, K. S. (2000). Social Anxiety Scale for Adolescents: Normative data and further evidence of construct validity. Journal of Abnormal Child Psychology, 29, 360–371. http://dx.doi.org/10. 1207/S15374424JCCP2903 7 Kelly, M. A., Didie, E. R., & Phillips, K. A. (2014). Personal and appearance-based rejection sensitivity in body dysmorphic disorder. Body Image, 11, 260–265. http://dx.doi.org/10.1016/j.bodyim.2014.03.004
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