Appearance comparison in individuals with body dysmorphic disorder and controls
Introduction
Body dysmorphic disorder (BDD) is characterized by a preoccupation relating to one or more perceived defects or flaws in appearance that are not observable or appear slight to others, which causes significant distress or impairment in functioning (American Psychiatric Association, 2013). One of the most commonly reported and problematic BDD-related behaviors consists of comparison of self to others in terms of physical appearance, either in public or social situations, or in the media (Lambrou et al., 2012, Phillips, 1991, Phillips et al., 2006). Indeed, Phillips (2005) observed that “comparing is the most common BDD behavior of all” (p. 106). On the basis of clinical observations, when BDD patients do compare their appearance to others they tend to compare the specific body part that is causing concern with the same body part of others. Phillips (2005) noted that individuals with BDD often judge themselves unfavorably in such comparisons and as a result frequently feel more distressed, and she also pointed out that comparing is time-consuming and can interfere with concentration, particularly when the individual is interacting with others. Veale and colleagues have argued that appearance comparison is one of a number of core problematic behaviors that maintain BDD symptoms by reinforcing selective attention to perceived defects and self-focus on a distorted internal image (Neziroglu et al., 2008, Veale, 2004, Veale et al., 1996).
Despite the reported high frequency of appearance comparison in BDD, published research investigating this behavior in the disorder is very limited. In one study, which included an investigation of BDD-related behaviors in adults with BDD, Phillips et al. (2006) found that 95.7% of participants reported a lifetime history of comparing their appearance to others, which was the highest percentage reported for the various behaviors investigated in the study. In another study, which investigated the frequency and distress associated with a number of appearance-related behaviors in BDD participants and controls over the past week, Lambrou et al. (2012) found that individuals with BDD reported a mean frequency of comparing to others of 4.0 (1.2), and a mean level of distress associated with comparing of 3.4 (1.4), on scales ranging from 0 to 5 where higher scores indicated higher levels of comparing and distress respectively. These scores represented the highest levels of frequency and distress associated with the different behaviors investigated in the study. Both of the above studies included a brief investigation of appearance comparison in BDD as part of a wider study, and there have been no published studies, to the authors’ knowledge, exploring in more detail the specific nature and effect of this behavior in BDD.
There has, however, been extensive research on appearance comparison in the field of body image, which can guide hypotheses on the nature and effect of appearance comparison in individuals with BDD. It has been proposed by researchers in the field that the comparison process is a core factor in development and maintenance of distorted body image, related maladaptive behaviors and disorder progression (Cash, 2008, Stormer and Thompson, 1996, Thompson, 1996, Thompson et al., 1999).
Theories of appearance comparison developed from social comparison theory (Festinger, 1954), which proposes that people are inclined to self-appraise their traits and commonly examine others in contexts relevant to themselves, drawing comparisons to inform self-evaluation. Research into social comparison suggests that comparison targets tend to be “particularistic”, involving comparison on the basis of distinct similarity to the target in terms of characteristics or attributes, for example someone of the same age or sex (Festinger, 1954, Miller et al., 1988, Wood, 1989). These authors have also noted that comparisons can be “upward”, comparing the self to someone perceived as “better-off”, or “downward”, comparing the self to someone perceived as “worse-off”. In addition, theories of social comparison suggest that the tendency to compare, as well as the impact of the comparing process, may be higher depending on the importance and self-relevance to the individual of the dimension under comparison (see Wood, 1989, for a review).
Research studies in the area of body image have found that greater levels of appearance comparison are associated with higher levels of body dissatisfaction (Heinberg and Thompson, 1992, Thompson et al., 1991). Furthermore, a higher frequency of upward comparisons has been found to be associated with more negative appearance evaluation and body dissatisfaction (Bailey and Ricciardelli, 2010, Leahey et al., 2007, Myers and Crowther, 2009, Stormer and Thompson, 1996, Tantleff-Dunn and Gokee, 2002). Consistent with the above associations, Leahey et al. (2007) also found that women with high body dissatisfaction, as compared to those with low body dissatisfaction, engage in a greater number of comparisons overall, as well as a higher proportion of upward comparisons.
Given the reported frequency of appearance comparison in BDD, and the wealth of research evidence indicating that this process is a core factor in the development and maintenance of body dissatisfaction, the aim of this study was to investigate the self-reported extent and nature of appearance comparison in individuals with BDD relative to controls. Specifically, the study aimed to explore self-reported frequency of comparing to same sex targets in terms of overall appearance and specific feature(s)/body part(s) of concern, as well as the frequency of comparing to same sex targets in terms of level of attractiveness. A further objective of the study was to explore individuals’ ratings of the attractiveness of targets in comparison to themselves, and the effect of appearance comparison on body satisfaction. The above factors were explored using a new measure of self-reported appearance comparison, as well as a standardized appearance comparison measure. The purpose of devising a new measure was to investigate specific components of appearance comparison in BDD as part of an exploratory study, rather than to develop and validate a new measure in itself. A new scale was devised, as there was no published scale at the time of conducting the research, to the authors’ knowledge, specifically investigating these components.
The hypotheses were as follows: (1) In comparison to controls, BDD participants would report higher levels of appearance comparison to same sex targets in terms of both overall appearance and specific features/body parts of concern; (2) Reported frequency of appearance comparison to same sex targets would be higher in terms of specific features/body parts of concern as compared to overall appearance in BDD participants, with the opposite pattern occurring in controls; (3) In terms of both overall appearance and specific features/body parts of concern, frequency of comparing to same sex targets in both groups would be higher for attractive targets in comparison to average targets, and higher for average targets in comparison to unattractive targets; (4) Attractiveness ratings of self compared to same sex others would be significantly more negative in BDD participants as compared to controls for all types of target (general and attractive); (5) Changes in appearance satisfaction following comparison to same sex targets would be more negative for BDD participants as compared to controls for all types of target (general and attractive); (6) BDD participants’ frequency of comparing to same sex targets in terms of both overall and specific features of appearance would be positively correlated with BDD severity; and (7) In both groups, frequency of comparing to same sex targets (in terms of both overall and specific features of appearance) would be positively correlated with levels of Appearance Orientation on the MBSRQ-AS (Cash, 2000), and negatively correlated with the following: levels of Appearance Evaluation and Body Areas Satisfaction on the MBSRQ-AS, self-ratings of attractiveness in comparison to others, and appearance satisfaction following comparing.
Section snippets
Participants
BDD participants were obtained from the following sources: current and former in-patients, out-patients and day-patients who had been assessed and/or treated at a National Health Service Mental Health Foundation trust in London, U.K. or at an independent psychiatric hospital in London, U.K.; individuals attending a monthly support group for people with BDD in London, U.K.; and volunteers responding to newsletter or online advertisements. Control participants comprised volunteers identified
Measures of Depression, Appearance Comparison, and Body Image
In order to compare the BDD and control group on the HADS-D, HADS-A, MBSRQ-AS, and BCS, GLM one-way between groups ANOVAs were performed. Table 2 shows the mean scores for each group and the results of the ANOVAs. BDD participants, as expected reported significantly higher levels of depression and anxiety than controls on the HADS-D and HADS-A respectively. On the BCS people with BDD, as expected, reported comparing their appearance to same sex others significantly more frequently than
Discussion
This study investigated self-reported appearance comparison in individuals with BDD and controls using a new measure, the ACI, and a standardized measure, the BCS (Fisher et al., 2002). The results of the ACI showed that as expected, BDD participants, when in public or social situations, or when viewing media images, report spending an extensive proportion of their time comparing their appearance to others of the same sex, in terms of both overall appearance and specific feature(s) of concern.
Acknowledgements
The authors acknowledge support from the National Institute of Health Research (NIHR) Biomedical Research Centre at the South London and Maudsley NHS Foundation Trust and King's College London. The authors are very grateful to Ana Costa and Fergal Jones for their helpful comments and suggestions regarding the manuscript, Daniel Stahl for his valuable advice on the statistical analysis, Susie Hales for her assistance in the recruitment and testing of healthy control participants, and Christina
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