19 May 2017

When beauty is not in the eye of the beholder

Your brain distorts your perception
of yourself in BDD.
by Anne Crawford

Body Dysmorphic Disorder (BDD) is a condition in which the individual is preoccupied or excessively concerned by what they see as flaws in their appearance, whether it’s the size or shape of their nose, the symmetry of their cheekbones or an imaginary defect elsewhere on their body.

The condition, along with its repetitive behaviours, can significantly affect lives, impacting on the ability to make friends, form relationships or be employed in a workplace, and can cause those with it to become so socially anxious that they are housebound. Around 60 per cent of BDD patients have preoccupations centred on their face; a number of them turning to cosmetic surgery as a treatment option.

Monash Alfred Psychiatry Research Centre (MAPrc) and Swinburne University researcher Dr Wei Lin Toh and colleagues have revealed some interesting, and potentially clinically helpful, insights into the way people with BDD process their own faces.

Their study, the latest of eight published as part of Dr Toh’s PhD, used for the first time eye-tracking technology to record and quantify the way people with BDD view their face. It involved 61 participants: 21 BDD patients, 19 obsessive-compulsive disorder (OCD) patients and 21 healthy controls who were matched for age, sex and IQ. Participants were asked to wear a device comprising a headband with two tiny cameras above their eyes, which recorded the way they responded to images of faces.

“We can record how many times they look at the part of the image, how many times they blink, the number of times they’re fixated on something and the saccades – when their eyes move quickly from one fixed point to another,” Dr Toh explained. “It gives us a comprehensive picture of how people look at things,” she said.

In a previous study, the participants were asked to view photos of strangers exhibiting six universal emotions – anger, disgust, fear, happiness, sadness, surprise – and a neutral control, and to pick the emotion the person in the image was exhibiting.

In this study, participants were asked, as an option, to view their own facial photograph; a third of those with BDD declined, possibly because this was distressing for them, Dr Toh said.

The study found that although the image of each BDD participant was taken with a neutral facial expression, that these people identified the emotion expressed in it as negative.

“Our main finding, which was novel, was that the people with BDD were less able to recognise the expression on their own face, picking negative emotions instead. This was more pronounced in people with a facial preoccupation and more severe BDD symptoms,” she said.

The researchers also carried out a small qualitative study of five BDD participants with facial preoccupations, mapping the way they looked at images of their own face. They found that these people had two distinct eye-tracking strategies – the first, in which they fixated on the area of their preoccupation, the other in which they avoided looking at this area. This differed from the “adaptive” approach to scanning a face used by most people, in which the eyes and the mouth are scanned in an inverted triangular pattern.

“What we hypothesise is that if they’re not scanning in the right way, this possibly contributes to them not being able to recognise people’s emotions,” Dr Toh said. “People with BDD typically have a high level of social anxiety about the way people judge their appearance – it’s possible that because they’re not processing stimuli in an adaptive way that this leads them to misinterpreting emotions and feeds back into them feeling bad about themselves.”

The study, published in the journal ‘Cognitive Neuropsychiatry’, was also conducted by Dr Toh’s supervisor, Professor Susan Rossell, Director of the Centre for Mental Health, Swinburne University and who holds an adjunct position at MAPrc, and Professor David Castle, Chair of Psychiatry, St Vincent’s Mental Health.

A Swinburne researcher is currently designing a visual retraining program to teach people with BDD how to properly scan faces.

Further research using neuroimaging techniques is underway.

The researchers are currently accepting potential research candidates for ongoing studies. To find out more information, or volunteer to participate in this research, please contact Fran Beilharz on (03) 9214 5614 or bddresearch@gmail.com.

Toh WL, Castle DJ, Rossell SL. How individuals with body dysmorphic disorder (BDD) process their own face: a quantitative and qualitative investigation based on an eye-tracking paradigm. Cogn Neuropsychiatry. 2017 May;22(3):213-232. doi: 10.1080/13546805.2017.1300090. Epub 2017 Mar 21.

Beilharz F, Castle DJ, Grace S, Rossell SL. A systematic review of visual processing and associated treatments in body dysmorphic disorder. Acta Psychiatr Scand. 2017 Feb 12. doi: 10.1111/acps.12705. [Epub ahead of print]

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