Dysmorphic concern is related to delusional proneness and negative affect in a community sample

Highlights

• Psychosis processes and negative emotionality are related to dysmorphic concern in a community sample.

• Delusion proneness and negative emotionality predict dysmorphic concern.

• Aberrant salience was not found to predict dysmorphic concern.

Abstract

Body image concerns are common in the general population and in some mental illnesses reach pathological levels. We investigated whether dysmorphic concern with appearance (a preoccupation with minor or imagined defects in appearance) is explained by psychotic processes in a community sample. In a cross-sectional design, two hundred and twenty six participants completed an online survey battery including: The Dysmorphic Concern Questionnaire; the Peters Delusional inventory; the Aberrant Salience Inventory; and the Depression, Anxiety, Stress Scale. Participants were native English speakers residing in Australia. Dysmorphic concern was positively correlated with delusional proneness, aberrant salience and negative emotion. Regression established that negative emotion and delusional proneness predicted dysmorphic concern, whereas, aberrant salience did not. Although delusional proneness was related to body dysmorphia, there was no evidence that it was related to aberrant salience. Understanding the contribution of other psychosis processes, and other health related variables to the severity of dysmorphic concern will be a focus of future research.

Introduction

A key developmental milestone in adolescence is the formation of a positive, realistic body image. Body image is a multifaceted construct consisting of physical, psychological (i.e., thoughts, feelings, attitudes towards one's body) and sociological components (Cash and Pruzinsky, 1990, Parks and Read, 1997, Roberts et al., 2006). Body image concerns can be the result of a distortion in perception, behaviour, or cognition and affect related to appearance (Castle et al., 2006). Typically, such concerns form part of a social norm, and do not result in pathological preoccupation or distress. In some cases, body image can be attributed such significance for an individual's self-concept that concerns contribute to diminished self-esteem and poorer psychological adjustment; for example, increased depression, anxiety, impaired sexual functioning and use of illegal substances (Smolak and Levine, 2001).

Dysmorphic concern with appearance describes an individual's pre-occupation with a minor or imagined defect in physical appearance (Castle and Rossell, 2006, Phillips et al., 1993) that usually appears only slight, or not observable to others (Castle et al., 2004). Dysmorphic concern is typically associated with considerable distress in clinical disorders including body dysmorphic disorder (BDD) (Castle et al., 2004, Mancuso et al., 2010). For example, evidence demonstrates that individuals with BDD experience increased levels of negative emotionality when compared with healthy controls (Kollei et al., 2012).

For some individuals with BDD, dysmorphic beliefs can be held with delusional levels of conviction (Mancuso et al., 2010) giving rise to the possibility that common processes are involved. Evidence in support of a potential role for delusional processes in BDD comes from a study in which 53% of individuals with BDD (n=224) were reported to have held the belief about their appearance “flaws” with delusional conviction for at least several weeks during the course of their illness–and were completely convinced that their belief was true and were unwilling to consider the possibility that it was not true (Phillips, 2004, Phillips et al., 1994, Phillips et al., 1993). Although delusions are traditionally associated with psychotic disorders, beliefs consistent with delusional themes arise in healthy samples, and there is evidence that delusional proneness represents a continuum (Peters et al., 2004, Van Os et al., 2000).

In the psychosis literature, a leading model of delusional beliefs is that they are associated with the aberrant assignment of salience or significance to otherwise innocuous stimuli (Kapur, 2003). Salience is usually attributed to stimuli which are experienced as inconsistent with what is expected (based on experience) and the surrounding context.

It has been proposed that salience becomes arbitrarily assigned to innocuous stimuli in psychosis leading to high levels of preoccupation with them, and the formation of strongly held explanatory beliefs in the form of delusions. In the context of BDD, a parallel process may be arising with body parts as a specific focus of attention, resulting in particular body parts being assigned salience.

The aim of this investigation was to determine whether psychosis related processes contribute to dysmorphic concern with appearance. We propose that these processes can be usefully investigated in terms of trait level variation in a general community population. We hypothesised that dysmorphic concern in a community based sample will be predicted by delusional ideation (reflecting delusion proneness) and more specifically by aberrant salience, when controlling for negative affect.

Outcomes of this research could illuminate potential mechanisms in the development of BDD, or the pathway from normative bodily concerns to clinical body dysmorphic concern, which may include delusional and emotional pathways.