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White matter microstructure in body dysmorphic disorder and its clinical correlates
... Diffusion Tensor Imaging studies have shown abnormal white matter tracts connectivity, mainly involving visual and emotion processing systems, as well as whole brain network disorganization, which indicates inefficient information transfer in BDD patients [13][14][15][16][17]. Functional stud-ies, employing resting state or task-based fMRI have revealed that BDD subjects exhibit functional abnormalities in visual processing 1 , frontostriatal 2 and limbic systems 3 [2,4,[18][19][20][21][22][23][24][25]. ...
... With respect to Diffusion Tensor Imaging studies, a study by Feusner et al. [15] revealed fiber disorganization in white matter tracts connecting visual and emotion/memory processing systems. Affected tracts were the inferior longitudinal fasciculus (ILF), which is involved in object and face recognition processes [36] and the forceps major (FM), which connects right and left visual processing systems [15]. ...
... With respect to Diffusion Tensor Imaging studies, a study by Feusner et al. [15] revealed fiber disorganization in white matter tracts connecting visual and emotion/memory processing systems. Affected tracts were the inferior longitudinal fasciculus (ILF), which is involved in object and face recognition processes [36] and the forceps major (FM), which connects right and left visual processing systems [15]. Poor integration of information between those regions may be correlated with poor insight and mediate the inability to accurately perceive and/or contextualize visual stimuli in individuals with BDD [37]. ...
Body dysmorphic disorder (BDD) is characterized by an individual's preoccupation with a perceived defect in their appearance which to others may be barely noticeable or even completely unnoticed. It confers significant disturbances of everyday functioning in affected persons. The present review study provides an overview of neuroimaging findings on BDD. Literature on three platforms, PubMed, Google Scholar and PsycArticles of APA PsycNet, was searched for studies on patients with BBD compared with healthy controls (HCs), with a focus on neuroimaging findings. Out of an initial yield of 414 articles, 23 fulfilled inclusion criteria and were reviewed. Among the most remarkable findings were functional abnormalities in visual processing, frontostriatal and limbic systems, reduced global efficiency of White Matter (WM) connectivity, reduced cortical thickness in temporal and parietal lobes, and correlations between these neuroimaging findings and clinical variables such as symptom severity and degree of insight. Structural, volumetric and functional neuroimaging findings in BDD affected persons may help shed light on the pathophysiology and neurobiological underpinnings of this condition. Future studies should further investigate the use of imaging findings as potential prognostic biomarkers of treatment efficacy and disease outcome.
... Overall, there was a substantial overlap in the patient cohort used across some of the included studies. Specifically, Diez et al. (2019); Ospina et al. (2019), Perez et al. (2017bPerez et al. ( , 2018aPerez et al. ( , 2018b and Williams et al. (2018) used the same CD sample; Li et al. (2018); Zhao et al. (2018) and Zhang et al. (2015) used the same SOD sample; Grace et al. (2017a), Buchanan et al. (2013Buchanan et al. ( , 2014, Arienzo et al. (2013) and Feusner et al. (2013) used the same BDD sample. ...
... However, this change in the BBD classification has attracted some criticism since the similarities observed between BDD and OCD were mostly based on indirect comparisons (Malcom et al., 2018). Table 3 shows characteristics of the 10 studies investigating GM (n = 6; (Atmaca et al., 2010b;Buchanan et al., 2014;Feusner et al., 2009;Grace et al., 2017a;Madsen et al., 2015;Rauch et al., 2003)) and WM (n = 4; Buchanan et al., 2013;Feusner et al., 2013;Zhang et al., 2016)) integrity in patients with BDD versus controls. Sample sizes ranged from 8 to 49 BBD patients for a total of 287 participants, including 144 patients and 143 controls. ...
... With regards to the four diffusion imaging studies, two investigated WM structure (Buchanan et al., 2013;Feusner et al., 2013) whereas the remaining two explored its organization and modularity (Zhang et al., 2016) in BDD patients compared to controls. Specifically, Buchanan et al. (2013) showed that BDD patients had disrupted WM integrity (i.e., lower FA) in most major connectivity tracts, including superior longitudinal fasciculus, inferior fronto-occipital fasciculus and corpus callosum (Buchanan et al., 2013). ...
Although there has been an increment in neuroimaging research in somatoform disorders (SD), yet little is known about the neural correlates of these diseases. Therefore, in this systematic review we aimed at summarizing the existing evidence of structural brain alterations in SD as per DSM-IV and DSM-5 criteria. Three electronic databases (Scopus, PubMed and Web of Science) were searched. Only case-control studies using structural neuroimaging were included. Forty-five out of 369 articles fulfilled inclusion criteria and were reviewed. Compared to controls, subjects with SD showed morphological alterations encompassing motor, limbic and somatosensory circuits. Although far from being conclusive, the results suggested that SD are characterized by selective alterations of large-scale brain networks implicated in cognitive control, emotion regulation and processing, stress and somatic-visceral perception. This review highlights the need for further multimodal neuroimaging studies with longitudinal designs, in larger and better-characterized samples, to elucidate the temporal and causal relationship between neuroanatomical changes and SD, which is paramount for informing tailored treatments.
... Overall, bias in study methodology was low (see Supplementary material II), however, upon review of patient characteristics, there was substantial overlap in the patient cohort used across all of the included studies: Bohon et al. (2012); Feusner et al. (2010b); Leow et al. (2012) used the same sample; Buchanan et al. (2014); Buchanan et al. (2013); Grace et al. (2017) used the same sample; Feusner et al. (2007) ;Feusner et al. (2009);Li et al. (2015a,b) used the same sample; and Arienzo et al. (2013); Feusner et al. (2013) used the same sample. ...
... Structural network analyses. Two studies have examined the white matter structure of BDD patients using diffusion-weighted MRI techniques (Buchanan et al., 2013;Feusner et al., 2013), which maps white matter fibre structure through assessing the diffusion of water molecules. Buchanan et al. (2013) used tract-based spatial statistics (TBSS; Smith et al., 2006) to measure fractional anisotropy (FA) in BDD patients. ...
... The BDD group demonstrated lower FA in white matter tracts that connect the hemispheres and frontal, parietal, occipital and temporal lobes relative to controls (Buchanan et al., 2013). Feusner et al. (2013) used probabilistic tractography to determine connectivity between visual processing, frontostriatal, and limbic systems, as well as TBSS, to conduct exploratory analyses on whole-brain white matter in BDD patients and healthy controls. There were no significant between-group differences in the white matter within the selected structural pathways and no significant group differences in whole-brain white matter . ...
There has been an increase in neuroimaging research in body dysmorphic disorder (BDD), yet little is known about the underlying neurobiological basis of the disorder. We aimed to provide a systematic overview of the literature on the neurobiology of BDD. Two reviewers undertook a search of three electronic research databases: PubMed, PsycINFO, and Google Scholar. The search consisted of synonyms commonly associated with BDD and methods to evaluate brain structure, function, and network organisation. Out of an initial yield of 175 articles, 19 fulfilled inclusion criteria and were reviewed. We identified differences in brain activity, structure, and connectivity in BDD participants in frontostriatal, limbic, and visual system regions when compared to healthy control and other clinical groups. We put forth a neurobiological model of BDD pathophysiology that involves wide-spread disorganisation in neural networks involved in cognitive control and the interpretation of visual and emotional information. This review considers how this model might aid in the development of future research and understanding of BDD.
... Abnormal visual processing in BDD may contribute to BSE inaccuracies. Individuals with BDD show selective visual attention biases (Greenberg et al., 2014;Grocholewski et al., 2012;Kollei et al., 2017;Toh et al., 2017b), greater sensitivity to details that may not be apparent to others (Feusner et al., 2010a;Toh et al., 2017a), disturbances in functional neural systems responsible for global visual perception for viewing own-and others' faces as well as houses and bodies (Feusner et al., 2007;Feusner et al., 2010b, Feusner et al., 2011, Li et al., 2015a, Li et al., 2015bMoody et al., 2021,Wong et al., 2021Wong et al., 2022, and disturbances in white-and gray matter structure in visual systems Feusner et al., 2013. These factors can enter a feedback loop with compulsive behaviours such as checking the mirror frequently and fixating on body parts, or else completely avoiding mirrors and abstaining from looking at their body (Castle et al., 2021), all of which may contribute to further attentional biases. ...
A core feature of body dysmorphic disorder (BDD) is body image disturbance. Many with BDD misperceive and are dissatisfied with the sizes and shapes of body parts, but detailed quantification and analysis of this has not yet been performed. To address this gap, we applied Somatomap 3D, a digital avatar tool, to quantify body image disturbances by assessing body size estimation (BSE) accuracy and body dissatisfaction. Sixty-one adults (31 with BDD, 30 healthy controls) created avatars to reflect their perceived current body and ideal body by altering 23 body part sizes and lengths using Somatomap 3D. Physical measurements of corresponding body parts were recorded for comparison. BSE accuracy (current minus actual) and body dissatisfaction (ideal minus current) were compared between groups and in relation to BDD symptom severity using generalized estimating equations. Individuals with BDD significantly over-and underestimated certain body parts compared to healthy controls. Individuals with BDD overall desired significantly thinner body parts compared to healthy controls. Moreover, those with worse BSE accuracy had greater body dissatisfaction and poorer insight. In sum, this digital avatar tool revealed disturbances in body image in individuals with BDD that may have perceptual and cognitive/affective components.
... inferior frontal gyrus and the right amygdala) (Buchanan et al., 2014;Feusner et al., 2009). Abnormalities in white matter connections across the hemispheres and all four lobes of the brain have also been noted in BDD, particularly when transferring visual information across regions involved with lower and higher order visual processing, emotion processing and memory systems (Buchanan et al., 2013;Feusner et al., 2013). Functionally, functional magnetic resonance imaging (fMRI) studies indicate reduced activity in primary and secondary visual cortices when viewing a range of stimuli among BDD participants (Feusner et al., 2010;Feusner, Townsend, Bystritsky, & Bookheimer, 2007;Li, Lai, Bohon, et al., 2015;Moody et al., 2015). ...
Body dysmorphic disorder (BDD) is characterised by a preoccupation with perceived flaws in appearance, which significantly disrupts functioning and causes distress. The difference in self-perception characteristic of BDD has been related to a bias in visual processing across a variety of stimuli and tasks. However, it is unknown how BDD participants perform on basic saccade tasks using eye tracking. Eighteen BDD and 21 healthy control participants completed a battery of saccadic eye movement tasks (fixation, prosaccade, anti-saccade, and memory guided). No significant differences were noted between the groups regarding behavioural performance or patterns of eye movements; however, there was a trend for BDD participants to make increased anticipatory errors on the prosaccade task. Overall, BDD participants demonstrated largely intact saccadic eye movement characteristics which may differentiate BDD from other obsessive-compulsive related disorders, although future research using larger samples is required. It is consequently argued that abnormalities in visual processing apparent among people with BDD may reflect abnormalities in higher-order visual systems.
... BDD has been associated with incidences of abnormal connectivity in the brain [3,28]. Although the primary aim of employing a composite psychedelics/VR intervention to BDD sufferers would be to evoke a perceptual change, we may additionally speculate a possible mitigation of the effects of such abnormalities. ...
... Studies in BDD have shown associations between obsessions and compulsions and activation in prefrontal, striatal, and visual regions [11]; with connectivity in the orbitofrontal cortex [12]; and with whole-brain white matter connectivity (global efficiency) [13]. Insight in BDD is associated with regional white matter diffusion in tracts relevant to visual processing [14]. ...
Anorexia nervosa (AN) and body dysmorphic disorder (BDD) share several phenomenological features including distorted perception of appearance, obsessions/compulsions, and limited insight. They also show partially overlapping patterns of brain activation, white matter connectivity, and electrophysiological responses. These markers have also shown associations with symptom severity within each disorder. We aimed to determine: (a) if, cross-diagnostically, neural activity and connectivity predict dimensional clinical phenotypes, and (b) the relative contribution of multimodal markers to these predictions beyond demographics and psychometrics, in a multivariate context. We used functional magnetic resonance imaging (fMRI) data from a visual task, graph theory metrics of white matter connectivity from diffusor tensor imaging, anxiety and depression psychometric scores, and demographics to predict dimensional phenotypes of insight and obsession/compulsions across a sample of unmedicated adults with BDD (n = 29) and weight-restored AN (n = 24). The multivariate model that included fMRI and white matter connectivity data performed significantly better in predicting both insight and obsessions/compulsions than a model only including demographics and psychometrics. These results demonstrate the utility of neurobiologically-based markers to predict important clinical phenotypes. The findings also contribute to understanding potential cross-diagnostic substrates for these phenotypes in these related but nosologically discrete disorders.
... Findings from structural MRI studies are mixed, with two studies reporting expansion of white matter volumes in patients with BDD as compared to controls [9,10] and a third study showing no difference between groups [11]. Studies have also found evidence of reduced white matter integrity in patients with BDD compared with controls [12][13][14]. In addition, cognitive studies show impaired executive function [15][16][17], recognition of facial emotion [18,19], attention [20], and cognitive flexibility, reward and motor impulsivity, and affective processing [21] in BDD. ...
Despite reasonable knowledge of body dysmorphic disorder (BDD), little is known of its cognitive antecedents. In this study, we evaluated executive functioning and decision-making in people at risk of developing BDD using neuropsychological tests. Participants were non-treatment seeking volunteers (18-29?years) recruited from the general community, and split into two groups: those "at risk" of developing BDD (N?=?5) and controls (N?=?82). Participants undertook the One-Touch Stockings of Cambridge, Cambridge Gamble and Spatial Working Memory tasks and were assessed with the Body Dysmorphic Disorder Questionnaire. Results showed that the at-risk subjects performed significantly worse on a measure of executive function, whereas measures of risk-seeking behavior, quality of decision-making, and spatial working memory were largely intact. The findings suggest that selective cognitive dysfunction may already be present in terms of executive functioning in those at risk of developing BDD, even before psychopathology arises.
... 7 AN differs from BDD in its greater prevalence in females and a generally less robust acute response to conventionally available treatments. 1 Recently, we showed that there are common and unique abnormalities in visual information processing of emotionally neutral faces stimuli for AN and BDD [8][9][10] and that there are irregularities in white matter microstructure in BDD involving visual systems. 11,12 Research in this aspect of perceptual distortion, as well as self-referential thought, is limited. In one study, when examining photographs of others' bodies, participants with AN rated underweight bodies to be more attractive and of more normal weight than did healthy comparison participants (HC). ...
Objective:
Individuals with anorexia nervosa (AN) and body dysmorphic disorder (BDD) exhibit distorted perception and negative evaluations of their own appearance; however, little is known about how they perceive others' appearance, and whether or not the conditions share perceptual distortions.
Method:
Thirty participants with BDD, 22 with AN, now weight-restored, and 39 healthy comparison participants (HC) rated photographs of others' faces and bodies on attractiveness, how overweight or underweight they were, and how much photographs triggered thoughts of their own appearance. We compared responses among groups by stimulus type and by level-of-detail (spatial frequency).
Results:
Compared to HCs, AN and BDD had lower attractiveness ratings for others' bodies and faces for high-detail and low-detail images, rated bodies as more overweight, and were more triggered to think of their own appearance for faces and bodies. In AN, symptom severity was associated with greater triggering of thoughts of own appearance and higher endorsement of overweight ratings for bodies. In BDD, symptom severity was associated with greater triggering of thoughts of own appearance for bodies and higher overweight ratings for low-detail images. BDD was more triggered to think of own facial appearance than AN.
Discussion:
AN and BDD show similar behavioral phenotypes of negative appearance evaluations for others' faces and bodies, and have thoughts of their own appearance triggered even for images outside of their primary appearance concerns, suggesting a more complex cross-disorder body-image phenotype than previously assumed. Future treatment strategies may benefit from addressing how these individuals evaluate others in addition to themselves. © 2016 Wiley Periodicals, Inc.(Int J Eat Disord 2017; 50:127-138).
... The proposed framework could be easily adapted to multimodal data obtained from other types of brain imaging as well (e.g., EEG or MEG data). Examples of practical applications may also include subsequent changes in structure and function during normal development or monitoring disease progression in various neuropsychiatric disorders [34][35][36][37][38]. In addition, the topology of brain connectome after dimensionality reduction could be compared groupwise in disease states, and/or could be regressed with respect to various dimensional phenotypic measures. ...
This paper describes novel methods for constructing the intrinsic geometry of the human brain connectome using dimensionality-reduction techniques. We posit that the high-dimensional, complex geometry that represents this intrinsic topology can be mathematically embedded into lower dimensions using coupling patterns encoded in the corresponding brain connectivity graphs. We tested both linear and nonlinear dimensionality-reduction techniques using the diffusion-weighted structural connectome data acquired from a sample of healthy subjects. Results supported the nonlinearity of brain connectivity data, as linear reduction techniques such as the multidimensional scaling yielded inferior lower-dimensional embeddings. To further validate our results, we demonstrated that for tractography-derived structural connectome more influential regions such as rich-club members of the brain are more centrally mapped or embedded. Further, abnormal brain connectivity can be visually understood by inspecting the altered geometry of these three-dimensional (3D) embeddings that represent the topology of the human brain, as illustrated using simulated lesion studies of both targeted and random removal. Last, in order to visualize brain’s intrinsic topology we have developed software that is compatible with virtual reality technologies, thus allowing researchers to collaboratively and interactively explore and manipulate brain connectome data.
... Previous research by the authors suggests abnormalities in the processing of configural and holistic visual information (Feusner et al. 2007(Feusner et al. , 2011 along with abnormalities in brain network organization and white-matter microstructure in BDD Buchanan et al. 2013;Feusner et al. 2013). Although several neuroimaging studies in AN suggest abnormal brain activation when visually processing body images (Wagner et al. 2003;Uher et al. 2005;Sachdev et al. 2008) no studies have directly compared visual processing, or patterns of functional connectivity across BDD and ANan approach that may elucidate transdiagnostic neural phenotypes (Insel & Cuthbert, 2009). ...
Body dysmorphic disorder (BDD) and anorexia nervosa (AN) are both characterized by distorted perception of appearance. Previous studies in BDD suggest abnormalities in visual processing of own and others' faces, but no study has examined visual processing of faces in AN, nor directly compared the two disorders in this respect.
We collected functional magnetic resonance imaging data on 60 individuals of equivalent age and gender in each of three groups - 20 BDD, 20 weight-restored AN, and 20 healthy controls (HC) - while they viewed images of others' faces that contained only high or low spatial frequency information (HSF or LSF). We tested hypotheses about functional connectivity within specialized sub-networks for HSF and LSF visual processing, using psychophysiological interaction analyses.
The BDD group demonstrated increased functional connectivity compared to HC between left anterior occipital face area and right fusiform face area (FFA) for LSF faces, which was associated with symptom severity. Both BDD and AN groups had increased connectivity compared to HC between FFA and precuneous/posterior cingulate gyrus for LSF faces, and decreased connectivity between FFA and insula. In addition, we found that LSF connectivity between FFA and posterior cingulate gyrus was significantly associated with thoughts about own appearance in AN.
Results suggest similar abnormal functional connectivity within higher-order systems for face processing in BDD and AN, but distinct abnormal connectivity patterns within occipito-temporal visual networks. Findings may have implications for understanding relationships between these disorders, and the pathophysiology underlying perceptual distortions.
... The caudate is a major hub in frontostriatal circuits that, amongst other functions, mediate inhibitory control (Chamberlain et al., 2005;Menzies et al., 2008) and is disrupted in OCD. In OCD, the caudate is abnormally large and hyperactive, compared with findings in controls (Whiteside et al., 2004;Feusner et al., 2013) and, in BDD, the caudate is hyperactive when individuals view images of their own face compared with a familiar face (Feusner et al., 2010). Abnormal morphometry and activity in the caudate may relate to anxiety in BDD and OCD, and may be indirectly related to altered visual perception in BDD. ...
Individuals with body dysmorphic disorder (BDD) suffer from preoccupations with perceived defects in physical appearance, causing severe distress and disability. Although BDD affects 1-2% of the population, the neurobiology is not understood. Discrepant results in previous volumetric studies may be due to small sample sizes, and no study has investigated cortical thickness in BDD. The current study is the largest neuroimaging analysis of BDD. Participants included 49 medication-free, right-handed individuals with DSM-IV BDD and 44 healthy controls matched by age, sex, and education. Using high-resolution T1-weighted magnetic resonance imaging, we computed vertex-wise gray matter (GM) thickness on the cortical surface and GM volume using voxel-based morphometry. We also computed volumes in cortical and subcortical regions of interest. In addition to group comparisons, we investigated associations with symptom severity, insight, and anxiety within the BDD group. In BDD, greater anxiety was significantly associated with thinner GM in the left superior temporal cortex and greater GM volume in the right caudate nucleus. There were no significant differences in cortical thickness, GM volume, or volumes in regions of interest between BDD and control subjects. Subtle associations with clinical symptoms may characterize brain morphometric patterns in BDD, rather than large group differences in brain structure.
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... In schizophrenia, magnetic resonance imaging data show that hallucinations are accompanied by white matter changes that could affect language, emotion, and attention/perception networks (Curčić- Blake et al., 2013). Studies of "body dysmorphic disorder" also show white matter abnormalities, which, it was proposed, suggest a relationship between impairment in insight and "fiber disorganization" in tracts interconnecting visual with emotion/memory processing systems (Buchanan et al., 2013;Feusner et al., 2013). White matter abnormalities in autism (Egaas et al., 1995;Koul, 2005) could underlie network dysfunction in that spectrum of diseases as well. ...
The new mutant mouse shaking (shk) differs from other 'myelin mutants' in having a more stable neurological impairment and a much longer lifespan. We have shown that transverse bands (TBs), the component of the paranodal junction (PNJ) that attaches the myelin sheath to the axon, are present in the shk CNS in contrast to more severely affected mutants, where TBs are absent or rare. We have proposed that TBs are the major determinant underlying shk neurological stability and longevity. Here we report that TBs are abundant not only in the shk CNS but also in its PNS, which, as in other myelin mutants, is not as severely dysmyelinated as the CNS but does display structural abnormalities likely to affect impulse propagation. In particular, myelin sheaths are thinner than normal and some axonal segments lack myelin sheaths entirely. In addition, we establish that the shk mutation, previously localized to chromosome 17, is a quaking (qk) allele consisting of a 105 nucleotide insertion in the qk regulatory region that decreases qk transcription but does not extend to the Parkin and Parkin co-regulated genes, which are affected in the qk allele. We conclude: (1) Dysmyelination is less severe in the shk PNS than in the CNS, but TBs, which are present in both locations, stabilize the PNJs and prevent the progressive neurological deficits seen in mutants lacking TBs; (2) The insertional mutation in shk mice is sufficient to produce the characteristic neurological phenotype without involvement of the Parkin and Parkin co-regulated genes. J. Comp. Neurol., 2014. © 2014 Wiley Periodicals, Inc.
... Most recently, two diffusion tensor imaging (DTI) studies have investigated white matter integrity in BDD participants. The smaller of these studies (n = 14) found a significant negative correlation between white matter integrity and BDD symptoms (Feusner et al., 2013). The second DTI study found widespread white matter degradation in the BDD participants (Buchanan et al., 2013). ...
Objectives:
Body dysmorphic disorder (BDD) is characterized by a preoccupation with a misperceived flaw in appearance, causing significant distress and disability. Neuropsychological research has revealed deficits in executive function and inhibitory control of emotional responses. The few previous structural neuroimaging studies have had inconclusive findings and we aimed to take this field of research forward by contributing high quality structural data.
Methods:
To investigate regional brain volumes we compared 20 BDD participants and 20 matched controls using high-resolution structural T1-weighted magnetic resonance imaging (MRI). The MRI data was subjected to cortical reconstruction and volumetric segmentation using Freesurfer software.
Results:
Results showed the right orbitofrontal cortex, bilateral thalamus, left anterior cingulate cortex, hippocampus and amygdala were significantly smaller in the BDD sample compared to controls. The most pronounced differences were in the right orbitofrontal cortex and left anterior cingulate cortex, as these areas were smaller in BDD participants independent of reduced global brain volumes. Duration of illness significantly negatively correlated with right orbitofrontal cortex volumes.
Conclusions:
This is the largest volumetric neuroimaging study in BDD to date and provides important data on volumetric differences that implicate fronto-limbic circuits.
Phenomenological observations of individuals with body dysmorphic disorder (BDD), coupled with evidence from neuropsychological, psychophysical, and neuroimaging studies, support a model of aberrant visual perception characterized by deficient global/holistic, enhanced detail/local processing, and selective visual-attentional biases. These features may contribute to the core symptomatology of distorted perception of their appearance, in addition to misinterpretation of others’ facial expressions and poor insight regarding their misperceived appearance defects. Insights from visual processing studies can contribute to the development of novel interventions, such as perceptual retraining and non-invasive neuromodulation. However, much remains to be understood about visual perception in BDD. Future research should leverage brain imaging modalities with high temporal resolutions and employ study designs that induce conflicts in multisensory integration, thereby advancing our mechanistic understanding of distorted visual perception observed in BDD.
Resumo A definição do espectro obsessivo-compulsivo indica um conjunto de transtornos que se caracterizam por pensamentos obsessivos (ob-sessões) e por comportamentos repetitivos ou atos mentais (compul-sões). O desenvolvimento desses transtornos associa-se a uma base multifatorial que abrange fatores de ordem genética, neurológica, e psicológica. O presente artigo objetiva revisar alguns aspectos que englobam os principais aspectos sintomatológicos dos transtornos que integram o espectro obsessivo-compulsivo e as teorias explicativas que incluem os aspectos de ordem genética, neurológica e psicológica. Palavras-chave: Obsessão-Compulsão. Genética. Neurologia. Psicologia. Abstract The definition of the obsessive-compulsive spectrum indicates a set of disorders that are characterized by obsessive thoughts (obsessions) and by repetitive behaviors or mental acts (compulsions).The development of these disorders is associated with a multifactorial base that encompasses genetic, neurological, and psychological factors.This article aims to review some aspects that encompass the main sympto-matological aspects of the obsessive-compulsive spectrum disorders, and the explanatory theories that include the genetic, neurological and psychological aspects.
Introduction: Body dysmorphic disorder is a debilitating disorder that often presents with significant delusionality, low insight, and both medical and psychiatric comorbidities, presenting a challenge for treatment and long-term management. Its typically chronic course requires that therapy be continued indefinitely, but only a few studies of long-term pharmacotherapeutic management exist.
Areas covered: The authors discuss the current understanding of body dysmorphic disorder, focusing specifically on: epidemiology, clinical presentation, challenges in treatment, treatment options, and the importance of the further study of the long-term management of the disorder.
Expert opinion: Serotonin reuptake inhibitors are the established drug of choice in patients with body dysmorphic disorder. Initial studies suggest that other agents such as augmentation antipsychotic medication may also be of use in combination with serotonin reuptake inhibitors, but there is a lack of studies comparing new treatments to serotonin reuptake inhibitors. Due to the chronic nature of body dysmorphic disorder, further research is needed to clarify the role of pharmacotherapy in long-term management and relapse prevention. Future studies should explore the long-term use of therapies and combinations of different therapeutics with the goal of effectively managing this debilitating, chronic condition.
A definição do espectro obsessivo-compulsivo indica um conjunto de transtornos que se caracterizam por pensamentos obsessivos (obsessões) e por comportamentos repetitivos ou atos mentais (compulsões). O desenvolvimento desses transtornos associa-se a uma base multifatorial que abrange fatores de ordem genética, neurológica, e psicológica. O presente artigo objetiva revisar alguns aspectos que englobam os principais aspectos sintomatológicos dos transtornos que integram o espectro obsessivo-compulsivo e as teorias explicativas que incluem os aspectos de ordem genética, neurológica e psicológica.
Body dysmorphic disorder (BDD) is defined by a recurring and persistent concern characterized by psychic suffering caused by a possible physical imperfection in appearance. It is a severe psychiatric condition, duly confirmed by neuroanatomical findings, very peculiar repetitive behaviors, and specific personalities. The prevalence of BDD is increasing around the world and differs between countries, because of cultural differences and different health-care systems. This increase is worrying because BDD is a pathology that presents comorbidity like severe depression, suicidal ideation, and functional and social impairment. However, BDD is an unrecognized and often not diagnosed in our society. Many patients are ashamed of their complaints and do not usually seek psychiatric help with ease, and unfortunately, they seek help in cosmetic and surgical treatments to improve their appearance, and these professionals are not yet prepared to assist in the diagnosis of this disorder. Therefore, this chapter presents not only the psychopathology of BDD but also its associations with other pathologies and their main factors of influence. Finally, we present a clinical experience with a detailed description of a clinical case. The aim is to contribute to the diagnosis and treatment of this pathology and also to future research that may benefit society and these patients.
This chapter discusses biological models and treatments for obsessive-compulsive and related disorders (OCRDs) in light of recent findings in the genetics and neurobiology of pediatric obsessive-compulsive disorder (OCD). It then describes major biological models proposed for OCD based on the understanding of the neurotransmitters, neurocircuitry and genetic factors implicated in OCRDs with an emphasis on the pediatric population. Next, the chapter also discusses pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS)/pediatric acute-onset neuropsychiatric syndrome (PANS), a proposed subtype of acute onset pediatric OCD. Three main neurotransmitters – serotonin, dopamine and glutamate – have been implicated in OCD. The chapter provides an overview of the evidence supporting an association with each of these neurotransmitters, with further discussion in the imaging and genetic sections which follow. Finally, it reviews the different classes of medications used for pediatric OCD, and new and innovative non-pharmacological approaches.
Somatoforme Störungen umfassen eine Gruppe heterogener Störungen, denen als führende klinische Beschwerden körperliche Symptome ohne eine hinreichende organmedizinische Erklärung gemeinsam sind. Dass Konzept der „Somatisierung“ liegt den somatoformen Störungen, aber auch anderen primären psychischen Störungen zugrunde, die wie z. B. Depression oder Angst vorrangig in ihren integralen körperlichen Symptomen dargestellt werden. Ursache, Entstehung und Aufrechterhaltung von somatoformen Störungen werden multifaktoriell vermittelt. Akute und chronische psychosoziale Stressoren spielen eine wichtige Rolle. Es kommen unterschiedliche Schweregrade und Verlaufstypen vor. Zu beachten sind eine bedeutsame psychiatrische Komorbidität, eine häufige psychosoziale Behinderung sowie eine intensive Inanspruchnahme vielfältiger medizinischer Ressourcen. Nicht selten gestaltet sich die Arzt-Patient-Beziehung emotional konfliktträchtig. Es existieren differenzierte störungsbezogene psychotherapeutische Ansätze. Pharmakotherapeutische Interventionen sind v. a. bei koexistenten psychischen Störungen indiziert, besitzen aber auch unabhängig davon eine gewisse Evidenzbasierung. Das diagnostische Konzept der somatoformen Störungen spielt bisher für die ärztliche Versorgung nur eine untergeordnete Rolle. Die Herausforderungen hier sind in erster Linie in der hohen Anzahl von Patienten zu sehen, die entweder nur vereinzelte oder nur wenige körperliche Symptome ohne mögliche somatisch-medizinische Zuordnung präsentieren und daher häufig nur „Symptom-Diagnosen“ erhalten, oder aber bei denen meist auf einer fachärztlichen Ebene ein fachspezifisch definiertes „funktionelles Körpersyndrom“ diagnostiziert wird. Beide eigenständigen diagnostischen Zugangsweisen sind häufig nicht spannungsfrei und klinisch sinnvoll in das psychiatrische Diagnosesystem übersetzbar. Das DSM-5 hat eine Reihe von formalen und inhaltlichen Kritikpunkten an der früheren Diagnosegruppe der „somatoformen Störungen“ aufgenommen und schlägt nunmehr die Gruppe der „somatischen Belastungsstörung und verwandter Störungen“ vor. Es ist derzeit noch unklar, zu welchen Positionen und Bezeichnungen die für die nächsten Jahre angekündigte Revision von ICD-11 kommen wird.
Individuals with Body Dysmorphic Disorder (BDD) are preoccupied with one or more perceived defects or flaws in their appearance that are not observable or appear only slight to others. More than one-third of individuals with BDD compulsively pick their skin to try to make it look better; however, because the picking can be time consuming and involve use of sharp implements such as pins, needles, or razor blades, it can cause considerable skin damage, which may require sutures or surgery to repair. Trichotillomania (TTM) is characterized by recurrent pulling out of one's hair. Hair is most commonly pulled from the scalp, eyebrows, or eyelids, but it may be pulled from axillary, facial, or pubic areas, or from any area of the body where hair grows. Excoriation (skin-picking) disorder (SPD) is new to DSM- 5. It is characterized by recurrent picking of one's skin.
We aim to provide a clinically focused review of the neurobiological literature in body dysmorphic disorder (BDD), with a focus on structural and functional neuroimaging.
There has been a recent influx of studies examining the underlying neurobiology of BDD using structural and functional neuroimaging methods. Despite obvious symptom similarities with obsessive-compulsive disorder (OCD), no study to date has directly compared the two groups using neuroimaging techniques. Studies have established that there are limbic and visual cortex abnormalities in BDD, in contrast to fronto-striatal differences in OCD. Such data suggests affect or visual training maybe useful in BDD.
© The Royal Australian and New Zealand College of Psychiatrists 2015.
Background: Body dysmorphic disorder (BDD) and anorexia nervosa (AN) share the clinical symptom of disturbed body image, which may be a function of perceptual distortions. Previous studies suggest visual or visuospatial processing abnormalities may be contributory, but have been unable to discern whether these occur early or late in the visual processing stream. We used electroencephalography (EEG) and visual event related potentials (ERP) to investigate early perceptual neural activity associated with processing visual stimuli.
Methods: We performed EEG on 20 AN, 20 BDD, 20 healthy controls, all unmedicated. In order to probe configural/holistic and detailed processing, participants viewed photographs of faces and houses that were unaltered or filtered to low or high spatial frequencies, respectively. We calculated the early ERP components P100 and N170, and compared amplitudes and latencies among groups.
Results: P100 amplitudes were smaller in AN than BDD and healthy controls, regardless of spatial frequency or stimulus type (faces or houses). Similarly, N170 latencies were longer in AN than healthy controls, regardless of spatial frequency or stimulus type, with a similar pattern in BDD at trend level significance. N170 amplitudes were smaller in AN than controls for high and normal spatial frequency images, and smaller in BDD than controls for normal spatial frequency images, regardless of stimulus type. Poor insight correlated with lower N170 amplitudes for normal and low spatial frequency faces in the BDD group.
Conclusions: Individuals with AN exhibit abnormal early visual system activity, consistent with reduced configural processing and enhanced detailed processing. This is evident regardless of whether the stimuli are appearance–or non-appearance-related, and thus may be a reflection of general, early perceptual abnormalities. As N170 amplitude could be a marker of structural encoding of faces, lower values may be associated with perceptual distortions and could contribute to poor insight in BDD. Future studies may explore visual ERP measures as potential biomarkers of illness phenotype.
The vestibular system has traditionally been thought of as a balance apparatus; however, accumulating research suggests an association between vestibular function and psychiatric and cognitive symptoms, even when balance is measurably unaffected. There are several brain regions that are implicated in both vestibular pathways and psychiatric disorders. The present review examines the anatomical associations between the vestibular system and various psychiatric disorders. Despite the lack of direct evidence for vestibular pathology in the key psychiatric disorders selected for this review, there is a substantial body of literature implicating the vestibular system in each of the selected psychiatric disorders. The second part of this review provides complimentary evidence showing the link between vestibular dysfunction and vestibular stimulation upon cognitive and psychiatric symptoms. In summary, emerging research suggests the vestibular system can be considered a potential window for exploring brain function beyond that of maintenance of balance, and into areas of cognitive, affective and psychiatric symptomology. Given the paucity of biological and diagnostic markers in psychiatry, novel avenues to explore brain function in psychiatric disorders are of particular interest and warrant further exploration.
Background and purpose:
ESRD results in excessive accumulation of urea and toxic metabolites. Hemodialysis is usually performed to maintain health in patients with ESRD; however, it may cause silent white matter alterations in the earlier stages. Hence, this study aimed to perform voxelwise diffusion tensor analysis for global detection of subtle white matter alterations in patients with ESRD.
Materials and methods:
Twenty-eight patients with ESRD and 25 age-matched control subjects were enrolled in this study. Each subject underwent CASI assessment and DTI. After spatial normalization of DTI images, voxelwise statistical analyses were performed to compare DTI parameters between the 2 groups.
Results:
In patients with ESRD, AD, RD, and MD values were significantly increased, whereas the FA value was significantly decreased, mostly in the corpus callosum, bilateral sagittal stratum, and pons. Multiple regression analysis further revealed that both RD and MD were positively correlated with the duration of hemodialysis in the pons; however, no significant correlation was observed with FA. Negative correlations of RD and MD and a positive correlation of FA with the CASI score were observed in the corona radiata.
Conclusions:
We concluded that voxelwise DTI analysis is helpful in the detection of white matter alterations caused by hemodialysis.
This book studies the organization of the white matter pathways of the brain. The book analyzes and synthesizes the corticocortical and corticosubcortical connections of the major areas of the cerebral cortex in the rhesus monkey. The result is a detailed understanding of the constituents of the cerebral white matter and the organization of the fiber tracts. The findings from the thirty-six cases studied are presented on a single template brain, facilitating comparison of the locations of the different fiber pathways. The summary diagrams provide a comprehensive atlas of the cerebral white matter. The text is enriched by close attention to functional aspects of anatomical observations. The clinical relevance of the pathways is addressed throughout the text and a chapter is devoted to human white matter diseases. The introductory account gives a detailed historical background. Translations of seminal original observations by early investigators are presented, and when these are considered in the light of the authors' new observations, many longstanding conflicts and debates are resolved.
Fractional anisotropy (FA), a widely used measure of fiber integrity based on diffusion tensor imaging (DTI), is theoretically confounded by several other quantities including the degree of fiber orientation incoherence within each voxel, and partial volume effects from neighboring gray matter or CSF. High angular resolution diffusion imaging (HARDI) can potentially resolve more complex diffusion geometries and thus disentangle confounds from fiber incoherence and partial voluming when assessing fiber integrity. Yet, to date, no study has systematically investigated the clinical implications of this potential advantage. Here, we describe our recent efforts in developing TDF (tensor distribution function) based probabilistic tractography for HARDI. Comparing TDF- and DTI-based tractography results in the genu of corpus callosum, we demonstrated the variable effect of these confounds in images acquired at different spatial resolutions, suggesting possible relevance of adjusting for fiber incoherence when assessing white matter integrity.
Localized amygdalar lesions in humans produce deficits in the recognition of fearful facial expressions. We used functional neuroimaging to test two hypotheses: (i) that the amygdala and some of its functionally connected structures mediate specific neural responses to fearful expressions; (ii) that the early visual processing of emotional faces can be influenced by amygdalar activity. Normal subjects were scanned using PET while they performed a gender discrimination task involving static grey-scale images of faces expressing varying degrees of fear or happiness. In support of the first hypothesis, enhanced activity in the left amygdala, left pulvinar, left anterior insula and bilateral anterior cingulate gyri was observed during the processing of fearful faces. Evidence consistent with the second hypothesis was obtained by a demonstration that amygdalar responses predict expression-specific neural activity in extrastriate cortex.
Perceptual organization (PO) refers to the processes by which visual information is structured into coherent patterns such as groups, contours, perceptual wholes, and object representations. Impairments in PO have been demonstrated in schizophrenia since the 1960s and have been linked to several illness-related factors including poor premorbid functioning, poor prognosis, and disorganized symptoms. This literature was last reviewed in 2005. Since then, electrophysiological (electroencephalographic, event-related potential, and magnetoencephalographic) and fMRI studies in both patient and nonpatient samples have clarified brain mechanisms involved in the impairment, and additional behavioral studies in patients and nonpatients have clarified the computational mechanisms. In addition, data now exist on the functional consequences of PO impairments, in terms of secondary difficulties in face processing, selective attention, working memory, and social cognition. Preliminary data on drug effects on PO and on changes in response to treatment suggest that anomalies in PO may furnish a biomarker for the integrity of its associated biological mechanisms. All of this recent evidence allows for a clearer picture of the nature of the impairment and how it relates to broader aspects of brain and behavioral functioning in schizophrenia.
Previous diffusion tensor imaging (DTI) studies in patients with obsessive-compulsive disorder (OCD) have reported inconsistent findings, and it is not known whether observed findings are related to abnormalities in axonal structure or myelination.
In this DTI study, we investigated fractional anisotropy, as well as axial and radial diffusivity, in 21 patients with OCD and 29 healthy controls.
We found decreased fractional anisotropy in the body of the corpus callosum in the OCD group, which was underpinned by increased radial diffusivity. Limitations: The cross-sectional design was the main limitation.
Our findings of increased radial diffusivity provide preliminary evidence for abnormal myelination in patients with OCD.
Perceptual filling-in occurs when visual stimuli are recognized in impoverished viewing conditions. Whether missing information is filled-in during face perception and which stages might be involved in this process are still unresolved questions. Because an identity can be brought to mind by seeing eyes only, we hypothesized that missing information might be filled-in from a memory trace for the whole face identity. We presented participants with faces in phase 1 and later we presented eyes-only in phase 2. For some of these eyes in phase 2, the whole face had been presented in the previous phase, for others identical eyes had been presented. Event-related potentials (ERPs) revealed an N170 component that was more negative when eyes were preceded by a whole face in the previous phase compared to eyes preceded by identical eyes-only. A more positive-going late positive complex (LPC) was also found, suggesting enhanced retrieval of face memory representations when eyes were preceded by whole faces. Our results show that pre-existing representations of face identity can influence early stages of visual encoding, 170 ms after stimulus onset. These effects may reflect top-down modulation by memory on visual recognition processes by filling-in the missing facial information.
There is increasing evidence of white matter abnormalities in patients with obsessive-compulsive disorder (OCD). The results of previous diffusion tensor imaging (DTI) studies, however, are inconsistent. Reasons for this inconsistency may include methodological issues such as misregistration, the differences in smoothing voxel-based morphometry style analysis or both. To date there are no DTI studies with tract-based spatial statistics (TBSS) which overcome these issues. In addition, previous studies had few drug-free patients, thus potentially reducing their power and obscuring their findings. Therefore, the aim of present study was to investigate white matter abnormalities using DTI and TBSS analysis in a large sample of drug-free patients with OCD. Thirty drug-free patients with OCD and 30 healthy controls underwent DTI. Fourteen of 30 patients were drug naïve. Voxel-wise group comparison of white matter fractional anisotropy (FA) was performed using TBSS. Compared to healthy volunteers, OCD patients had statistically less FA in the anterior body of corpus callosum (CC) (p < .05, corrected). They also had a trend for a lower FA in the large portion of CC, the right cingulum, and the left anterior limb of internal capsule (ALIC). There were no areas of the brain with significantly higher FA. This is the first study that has investigated white matter abnormalities in non-medicated patients with OCD using DTI and TBSS analyses. Microstructural white matter abnormalities in the CC, the cingulum, and the ALIC might be involved in the pathophysiology of OCD.
An array of cortical and subcortical structures have been implicated in the recognition of emotion from facial expressions. It remains unknown how these regions communicate as parts of a system to achieve recognition, but white matter tracts are likely critical to this process. We hypothesized that (1) damage to white matter tracts would be associated with recognition impairment and (2) the degree of disconnection of association fiber tracts [inferior longitudinal fasciculus (ILF) and/or inferior fronto-occipital fasciculus (IFOF)] connecting the visual cortex with emotion-related regions would negatively correlate with recognition performance. One hundred three patients with focal, stable brain lesions mapped onto a reference brain were tested on their recognition of six basic emotional facial expressions. Association fiber tracts from a probabilistic atlas were coregistered to the reference brain. Parameters estimating disconnection were entered in a general linear model to predict emotion recognition impairments, accounting for lesion size and cortical damage. Damage associated with the right IFOF significantly predicted an overall facial emotion recognition impairment and specific impairments for sadness, anger, and fear. One subject had a pure white matter lesion in the location of the right IFOF and ILF. He presented specific, unequivocal emotion recognition impairments. Additional analysis suggested that impairment in fear recognition can result from damage to the IFOF and not the amygdala. Our findings demonstrate the key role of white matter association tracts in the recognition of the facial expression of emotion and identify specific tracts that may be most critical.
There has been dearth of investigations concerning morphometric magnetic resonance imaging (MRI) study of regional brain volumes in body dysmorphic disorder (BDD). So we performed a volumetric MRI study in patients with BDD focusing on the in vivo neuroanatomy of thalamus, caudate nucleus, anterior cingulate cortex, and orbito-frontal cortex (OFC) concurrently.
The whole brain, total gray and white matter volume, thalamus, caudate nucleus, anterior cingulate cortex, and OFC volumes were blindly measured in 12 unmedicated male BDD patients not having any comorbidity and 12 male control subjects matched for age, and gender.
The mean OFC and anterior cingulate volumes were significantly smaller than those of healthy controls. The mean white matter volume was larger than that of controls. There was a trend toward increased thalamic volume in patients compared with that of control subjects. Length of illness was inversely correlated with OFC volumes in the patient group both on the left and right sides.
These findings may be interpreted as further evidence for the inclusion of BDD among a group of obsessive-compulsive spectrum disorders. Future research is necessary to confirm these preliminary findings, to extend them, and to clarify their significance with respect to the etiology and pathophysiology of BDD.
The functional dissociation of human extrastriate cortical processing streams for the perception of face identity and location was investigated in healthy men by measuring visual task-related changes in regional cerebral blood flow (rCBF) with positron emission tomography (PET) and H2(15)O. Separate scans were obtained while subjects performed face matching, location matching, or sensorimotor control tasks. The matching tasks used identical stimuli for some scans and stimuli of equivalent visual complexity for others. Face matching was associated with selective rCBF increases in the fusiform gyrus in occipital and occipitotemporal cortex bilaterally and in a right prefrontal area in the inferior frontal gyrus. Location matching was associated with selective rCBF increases in dorsal occipital, superior parietal, and intraparietal sulcus cortex bilaterally and in dorsal right premotor cortex. Decreases in rCBF, relative to the sensorimotor control task, were observed for both matching tasks in auditory, auditory association, somatosensory, and midcingulate cortex. These results suggest that, within a sensory modality, selective attention is associated with increased activity in those cortical areas that process the attended information but is not associated with decreased activity in areas that process unattended visual information. Selective attention to one sensory modality, on the other hand, is associated with decreased activity in cortical areas dedicated to processing input from other sensory modalities. Direct comparison of our results with those from other PET-rCBF studies of extrastriate cortex demonstrates agreement in the localization of cortical areas mediating face and location perception and dissociations between these areas and those mediating the perception of color and motion.
Objective:
In clinical samples, body dysmorphic disorder (BDD) is associated with substantial suffering and reduced quality of life. Limited surveys report widely varying prevalence estimates. To better establish the prevalence of BDD, we conducted a United States nationwide prevalence survey.
Method:
We conducted a random sample national household telephone survey in the spring and summer of 2004 and interviewed 2,513 adults, of whom 2,048 qualified for the BDD-module administration. The computer-assisted, structured interviews, conducted by trained lay interviewers, addressed Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria for BDD, along with information regarding several impulse-control disorders and the respondents' financial and demographic data.
Results:
The rate of response was 56.3%, which compared favorably with rates in federal national health surveys. The cooperation rate was 97.6%. Respondents included a higher percentage of women and people >55 years of age than in the US adult population, and a lower percentage of Hispanics. The estimated point prevalence of DSM-IV BDD among respondents was 2.4% (49/2,048) (by gender: 2.5% for women, 2.2% for men), exceeding the prevalence of schizophrenia and bipolar disorder type I and about that of generalized anxiety disorder. BDD prevalence decreased after 44 years of age, and a larger proportion of BDD respondents were never married. Of those meeting DSM-IV criteria for BDD, 90% (45/49) met the DSM-IV distress criterion, and 51% (25/49) met the interference-with-functioning criterion.
Conclusion:
A study using clinically valid interviews is needed to evaluate these results. Such studies could inform treatment by documenting rates of seeking treatment from various sources, suicide attempt rates, and the prevalence of comorbid conditions.
This study assessed demographic and clinical features in 65 subjects with body dysmorphic disorder (BDD) and compared the 39 (60%) with the delusional form (receiving an additional diagnosis of delusional disorder, somatic type) with those who did not meet delusionality criteria. Delusional and nondelusional patients did not statistically differ on most demographic and clinical variables. Delusional patients, however, had significantly more severe BDD symptoms at both baseline and follow-up assessments than those of nondelusional patients. Furthermore, poorer insight was significantly associated with more severe BDD symptoms at both baseline and follow-up. Overall improvement in BDD symptom severity was similar for the 2 groups. Our results support other studies in the view that BDD and its delusional variant have more similarities than differences and that the delusional variant may be simply a more severe form of BDD. Implications for the diagnostic classification of BDD and future research directions are discussed.
Localized amygdalar lesions in humans produce deficits in the recognition of fearful facial expressions. We used functional neuroimaging to test two hypotheses: (i) that the amygdala and some of its functionally connected structures mediate specific neural responses to fearful expressions; (ii) that the early visual processing of emotional faces can be influenced by amygdalar activity. Normal subjects were scanned using PET while they performed a gender discrimination task involving static grey-scale images of faces expressing varying degrees of fear or happiness. In support of the first hypothesis, enhanced activity in the left amygdala, left pulvinar, left anterior insula and bilateral anterior cingulate gyri was observed during the processing of fearful faces. Evidence consistent with the second hypothesis was obtained by a demonstration that amygdalar responses predict expression-specific neural activity in extrastriate cortex.
The aim was to investigate the white matter abnormalities of drug-naïve patients with obsessive-compulsive disorder (OCD) using diffusion tensor-imaging and the white matter changes in the patients after pharmacotherapy.
Thirteen drug-naïve OCD patients and 13 age- and sex-matched healthy comparison subjects were examined using diffusion tensor-imaging and structural magnetic resonance imaging. Measurements were made in OCD patients before and after 12 weeks of citalopram treatment.
Compared with controls, the drug-naïve OCD patients showed significant increases in fractional anisotropy (FA) in the corpus callosum, the internal capsule and white matter in the area superolateral to the right caudate. The increases in FA were mostly no longer observed in patients after 12 weeks of treatment compared with controls.
Our findings suggest that white matter alterations are associated with the pathophysiology of OCD, and the abnormalities may be partly reversible with pharmacotherapy.
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The Bloch—Torrey equations are modified to include the case of anisotropic, restricted diffusion and flow. The problem of solving these modified equations for the amplitude of a spin echo in a time-dependent magnetic-field gradient subject to restricting boundary conditions is discussed. This problem is solved for a number of selected cases. In particular, it is found that a magnetic-field gradient applied in short, intense pulses is effective in defining the time during which nuclear displacements take place. A simplified equation, suitable for the pulsed-gradient experiment, is presented and solved for two different examples of systems showing restricted diffusion. A procedure for analyzing the data from pulsed-gradient measurements is suggested, and its merits are discussed. Suggestions are made of systems which may well be expected to show restricted, anisotropic diffusion or interesting flow properties.
The phenomenological Bloch equations in nuclear magnetic resonance are generalized by the addition of terms due to the transfer of magnetization by diffusion. The revised equations describe phenomena under conditions of inhomogeneity in magnetic field, relaxation rates, or initial magnetization. As an example the equations are solved in the case of the free precession of magnetic moment in the presence of an inhomogeneous magnetic field following the application of a 90° pulse with subsequent applications of a succession of 180° pulses. The spin-echo amplitudes agree with the results of Carr and Purcell from a random walk theory.
The obsessive–compulsive (OC) spectrum has been discussed in the literature for two decades. Proponents of this concept propose that certain disorders characterized by repetitive thoughts and/or behaviors are related to obsessive–compulsive disorder (OCD), and suggest that such disorders be grouped together in the same category (i.e. grouping, or “chapter”) in DSM. This article addresses this topic and presents options and preliminary recommendations to be considered for DSM-V. The article builds upon and extends prior reviews of this topic that were prepared for and discussed at a DSM-V Research Planning Conference on Obsessive–Compulsive Spectrum Disorders held in 2006. Our preliminary recommendation is that an OC-spectrum grouping of disorders be included in DSM-V. Furthermore, we preliminarily recommend that consideration be given to including this group of disorders within a larger supraordinate category of “Anxiety and Obsessive–Compulsive Spectrum Disorders.” These preliminary recommendations must be evaluated in light of recommendations for, and constraints upon, the overall structure of DSM-V. Depression and Anxiety, 2010. © 2010 Wiley-Liss, Inc.
Obsessive–compulsive disorder (OCD) is thought to involve large-scale brain systems but the anatomical connectivity via association fibers has not been specifically investigated yet.We evaluated organization and directionality of the major fiber bundles in a subpopulation of OCD, including washers and checkers who presented decision making deficits, by measuring MRI parameters related to water self-diffusion (Fractional Anisotropy, FA) and fiber directionality (Principal Diffusion Direction, PDD) in 15 OCD and 16 control subjects.OCD patients showed significantly lower FA and altered PDD along the corpus callosum, cingulum, superior longitudinal fasciculus, and inferior fronto-occipital fasciculus bilaterally. The track-based analysis of the inferior fronto-occipital fasciculus confirmed a significant bilateral FA reduction. Lower FA values in the inferior fronto-occipital fasciculus, superior longitudinal fasciculus and corpus callosum correlated with symptom severity and neuropsychological performance.This multi-parameter MRI study revealed specific white matter abnormalities in OCD suggesting tract disorganization as main feature, reflected by local changes in fiber directionality. This altered anatomical connectivity might play a specific role in OCD pathophysiology.
Increased interest in body dysmorphic disorder (BDD) has generated a wealth of recent research. This paper reviews the current literature regarding conceptualizations of the disorder, the development of assessment tools, and treatment outcome. Although BDD has been viewed as a variant of an eating disorder, obsessive compulsive disorder, or a somatoform disorder, it appears best conceptualized as a body image disorder with social, psychological, and possibly biological influences. Assessment instruments with acceptable psychometric properties have been developed to specifically assess BDD (e.g., the Body Dysmorphic Disorder Examination and the Yale–Brown Obsessive Compulsive Scale modified for Body Dysmorphic Disorder). Examination and the initial results from uncontrolled and controlled treatment research suggest that cognitive behavioral treatments for BDD may be as effective as those for possibly related disorders such as obsessive compulsive disorder and bulimia nervosa.
This paper presents processing and visualization techniques for Diffusion Tensor Magnetic Resonance Imaging (DT-MRI). In DT-MRI, each voxel is assigned a tensor that describes local water diffusion. The geometric nature of diffusion tensors enables us to quantitatively characterize the local structure in tissues such as bone, muscle, and white matter of the brain. This makes DT-MRI an interesting modality for image analysis. In this paper we present a novel analytical solution to the Stejskal-Tanner diffusion equation system whereby a dual tensor basis, derived from the diffusion sensitizing gradient configuration, eliminates the need to solve this equation for each voxel. We further describe decomposition of the diffusion tensor based on its symmetrical properties, which in turn describe the geometry of the diffusion ellipsoid. A simple anisotropy measure follows naturally from this analysis. We describe how the geometry or shape of the tensor can be visualized using a coloring scheme based on the derived shape measures. In addition, we demonstrate that human brain tensor data when filtered can effectively describe macrostructural diffusion, which is important in the assessment of fiber-tract organization. We also describe how white matter pathways can be monitored with the methods introduced in this paper. DT-MRI tractography is useful for demonstrating neural connectivity (in vivo) in healthy and diseased brain tissue.
Obsessive-compulsive disorder (OCD) is a common, heritable neuropsychiatric disorder, hypothetically underpinned by dysconnectivity of large-scale brain systems. The extent of white matter abnormalities in OCD is unknown, and the genetic basis of this disorder is poorly understood. The authors used diffusion tensor imaging, a magnetic resonance imaging technique, for examining white matter abnormalities in brain structure through quantification of water diffusion, to confirm whether white matter abnormalities exist in OCD. They also explored whether such abnormalities occur in healthy first-degree relatives of patients, indicating they may be endophenotypes representing increased genetic risk for OCD.
The authors used diffusion tensor imaging to measure fractional anisotropy of white matter in 30 patients with OCD, 30 unaffected first-degree relatives, and 30 matched healthy comparison subjects. Regions of significantly abnormal fractional anisotropy in patients in relation to healthy comparison subjects were identified by permutation tests. The authors assessed whether these abnormalities were also evident in the first-degree relatives. A secondary region-of-interest analysis was undertaken to assess the extent of replication between our data and previous relevant literature.
Patients with OCD demonstrated significantly reduced fractional anisotropy in a large region of right inferior parietal white matter and significantly increased fractional anisotropy in a right medial frontal region. Relatives also exhibited significant abnormalities of fractional anisotropy in these regions.
These findings indicate that OCD is associated with white matter abnormalities in parietal and frontal regions. Similar abnormalities in unaffected first-degree relatives suggest these may be white matter endophenotypes for OCD.
Individuals with body dysmorphic disorder (BDD) may have perceptual distortions for their appearance. Previous studies suggest imbalances in detailed relative to configural/holistic visual processing when viewing faces. No study has investigated the neural correlates of processing non-symptom-related stimuli. The objective of this study was to determine whether individuals with BDD have abnormal patterns of brain activation when viewing non-face/non-body object stimuli.
Fourteen medication-free participants with DSM-IV BDD and 14 healthy controls participated. We performed functional magnetic resonance imaging (fMRI) while participants matched photographs of houses that were unaltered, contained only high spatial frequency (HSF, high detail) information or only low spatial frequency (LSF, low detail) information. The primary outcome was group differences in blood oxygen level-dependent (BOLD) signal changes.
The BDD group showed lower activity in the parahippocampal gyrus, lingual gyrus and precuneus for LSF images. There were greater activations in medial prefrontal regions for HSF images, although no significant differences when compared to a low-level baseline. Greater symptom severity was associated with lower activity in the dorsal occipital cortex and ventrolateral prefrontal cortex for normal spatial frequency (NSF) and HSF images.
Individuals with BDD have abnormal brain activation patterns when viewing objects. Hypoactivity in visual association areas for configural and holistic (low detail) elements and abnormal allocation of prefrontal systems for details are consistent with a model of imbalances in global versus local processing. This may occur not only for appearance but also for general stimuli unrelated to their symptoms.
The eating disorder anorexia nervosa (AN) is associated with high anxiety. The brain mechanisms that drive those behaviors are unknown. In this study we wanted to test whether brain white matter (WM) integrity is altered in AN, and related to heightened anxiety. Sixteen adult women with AN (mean age 24 ± 7 years) and 17 healthy control women (CW, mean age 25 ± 4 years) underwent diffusion tensor imaging (DTI) of the brain. The DTI brain images were used to calculate the fractional anisotropy (FA) of WM tracts, which is a measure for WM integrity. AN individuals compared to CW showed clusters of significantly reduced FA (p<0.05, corrected) in the bilateral fimbria-fornix and the fronto-occipital fasciculus, as well as the posterior cingulum WM. In the AN group, Harm Avoidance was predicted by FA in the left and right fimbria-fornix. Those findings were not due to WM volume deficits in AN. This study indicates that WM integrity is abnormal in AN in limbic and association pathways, which could contribute to disturbed feeding, emotion processing and body perception in AN. The prediction of Harm Avoidance in AN by fimbria-fornix WM integrity suggests that this pathway may be mechanistically involved in high anxiety in AN.
The goals of this study were to first determine whether the fractional anisotropy (FA) and mean diffusivity (MD) of major white matter pathways associate with schizophrenia, and secondly to characterize the extent to which differences in these metrics might reflect a genetic predisposition to schizophrenia. Differences in FA and MD were identified using a comprehensive atlas-based tract mapping approach using diffusion tensor imaging and high-resolution structural data from 35 patients, 28 unaffected first-degree relatives of patients, 29 community controls, and 14 first-degree relatives of controls. Schizophrenia patients had significantly higher MD in the following tracts compared to controls: the right anterior thalamic radiations, the forceps minor, the bilateral inferior fronto-occipital fasciculus (IFO), the temporal component of the left superior longitudinal fasciculus (tSLF), and the bilateral uncinate. FA showed schizophrenia effects and a linear relationship to genetic liability (represented by schizophrenia patients, first-degree relatives, and controls) for the bilateral IFO, the left inferior longitudinal fasciculus (ILF), and the left tSLF. Diffusion tensor imaging studies have previously identified white matter abnormalities in all three of these tracts in schizophrenia; however, this study is the first to identify a significant genetic liability. Thus, FA of these three tracts may serve as biomarkers for studies seeking to identify how genes influence brain structure predisposing to schizophrenia. However, differences in FA and MD in frontal and temporal white matter pathways may be additionally driven by state variables that involve processes associated with the disease.
Social anxiety disorder (SAD) and body dysmorphic disorder (BDD) are two separate, but conceptually overlapping nosological entities. In this review, we examine similarities between SAD and BDD in comorbidity, phenomenology, cognitive biases, treatment outcome, and cross-cultural aspects. Our review suggests that SAD and BDD are highly comorbid, show a similar age of onset, share a chronic trajectory, and show similar cognitive biases for interpreting ambiguous social information in a negative manner. Furthermore, research from treatment outcome studies have demonstrated that improvements in SAD were significantly correlated with improvements in BDD. Findings from cross-cultural research suggest that BDD may be conceived as a subtype of SAD in some Eastern cultures. Directions for future research and clinical implications of these findings are discussed.
Individuals with body dysmorphic disorder (BDD) are preoccupied with perceived physical defects or flaws, often facial features, which may be due to distorted perception. Previous studies have demonstrated abnormalities in visual processing of faces and figures, and misinterpretations of emotional expressions. The objective of this study was to determine in BDD how viewing faces with emotional expressions affects perception on an identity-matching task. Twelve BDD subjects and 11 healthy controls matched identities of faces with emotional expressions, neutral expressions, and a control task of ovals and circles. The BDD group made twice as many errors relative to controls for identity-matching of faces with emotional expressions but not for neutral faces or ovals/circles. Mean reaction times were slower for the BDD relative to the control group for emotional faces in general, but there was no effect of specific emotion type. These data suggest that individuals with BDD have abnormalities in facial identification for faces with emotional expressions. This could reflect fundamental abnormalities in visual information processing that are more pronounced for emotional expressions in general, and may relate to their perceptual disturbances.
Body dysmorphic disorder (BDD) is characterised by a preoccupation with perceived defects in one's appearance, which leads to significant distress and/or impairment. Although several studies have investigated the prevalence of BDD, many studies have methodological limitations (e.g., small sample sizes and student populations), and studies on the prevalence of BDD in the general population are limited. In the current study, 2510 individuals participated in a representative German nationwide survey. Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) criteria for BDD and associated characteristics such as suicidality and the prevalence of plastic surgeries were examined using self-report questionnaires. The prevalence of current BDD was 1.8% (N=45). Further, individuals with BDD, relative to individuals without BDD, reported significantly more often a history of cosmetic surgery (15.6% vs. 3.0%), higher rates of suicidal ideation (31.0% vs. 3.5%) and suicide attempts due to appearance concerns (22.2% vs. 2.1%). The current findings are consistent with previous findings, indicating that self-reported BDD is a common disorder associated with significant morbidity.
To investigate the concurrent validity and reliability of the Mini International Neuropsychiatric Interview for Children and Adolescents (MINI-KID), a short structured diagnostic interview for DSM-IV and ICD-10 psychiatric disorders in children and adolescents.
Participants were 226 children and adolescents (190 outpatients and 36 controls) aged 6 to 17 years. To assess the concurrent validity of the MINI-KID, participants were administered the MINI-KID and the Schedule for Affective Disorders and Schizophrenia for School Aged Children-Present and Lifetime Version (K-SADS-PL) by blinded interviewers in a counterbalanced order on the same day. Participants also completed a self-rated measure of disability. In addition, interrater (n = 57) and test-retest (n = 83) reliability data (retest interval, 1-5 days) were collected, and agreement between the parent version of the MINI-KID and the standard MINI-KID (n = 140) was assessed. Data were collected between March 2004 and January 2008.
Substantial to excellent MINI-KID to K-SADS-PL concordance was found for syndromal diagnoses of any mood disorder, any anxiety disorder, any substance use disorder, any ADHD or behavioral disorder, and any eating disorder (area under curve [AUC] = 0.81-0.96, kappa = 0.56-0.87). Results were more variable for psychotic disorder (AUC = 0.94, kappa = 0.41). Sensitivity was substantial (0.61-1.00) for 15/20 individual DSM-IV disorders. Specificity was excellent (0.81-1.00) for 18 disorders and substantial (> 0.73) for the remaining 2. The MINI-KID identified a median of 3 disorders per subject compared to 2 on the K-SADS-PL and took two-thirds less time to administer (34 vs 103 minutes). Interrater and test-retest kappas were substantial to almost perfect (0.64-1.00) for all individual MINI-KID disorders except dysthymia. Concordance of the parent version (MINI-KID-P) with the standard MINI-KID was good.
The MINI-KID generates reliable and valid psychiatric diagnoses for children and adolescents and does so in a third of the time as the K-SADS-PL.
This study assessed demographic and clinical features in 65 subjects with body dysmorphic disorder (BDD) and compared the 39 (60%) with the delusional form (receiving an additional diagnosis of delusional disorder, somatic type) with those who did not meet delusionality criteria. Delusional and nondelusional patients did not statistically differ on most demographic and clinical variables. Delusional patients, however, had significantly more severe BDD symptoms at both baseline and follow-up assessments than those of nondelusional patients. Furthermore, poorer insight was significantly associated with more severe BDD symptoms at both baseline and follow-up. Overall improvement in BDD symptom severity was similar for the 2 groups. Our results support other studies in the view that BDD and its delusional variant have more similarities than differences and that the delusional variant may be simply a more severe form of BDD. Implications for the diagnostic classification of BDD and future research directions are discussed.
Body dysmorphic disorder (BDD) is a psychiatric disorder in which individuals are preoccupied with perceived defects in their appearance, often related to their face. Little is known about its pathophysiology, although early research provides evidence of abnormal visual processing.
To determine whether patients with BDD have abnormal patterns of brain activation when visually processing their own face with high, low, or normal spatial resolution.
Case-control study.
A university hospital.
Seventeen right-handed medication-free subjects with BDD and 16 matched healthy control subjects. Intervention Functional magnetic resonance imaging while viewing photographs of face stimuli. Stimuli were neutral-expression photographs of the patient's own face and a familiar face (control stimuli) that were unaltered, altered to include only high spatial frequency (fine spatial resolution), or altered to include only low spatial frequency (low spatial resolution).
Blood oxygen level-dependent signal changes in the BDD and control groups during each stimulus type.
Subjects with BDD showed relative hyperactivity in the left orbitofrontal cortex and bilateral head of the caudate for the unaltered own-face vs familiar-face condition. They showed relative hypoactivity in the left occipital cortex for the low spatial frequency faces. Differences in activity in frontostriatal systems but not visual cortex covaried with aversiveness ratings of the faces. Severity of BDD symptoms correlated with activity in frontostriatal systems and visual cortex.
These results suggest abnormalities in visual processing and frontostriatal systems in BDD. Hypoactivation in the occipital cortex for low spatial frequency faces may indicate either primary visual system abnormalities for configural face elements or top-down modulation of visual processing. Frontostriatal hyperactivity may be associated both with aversion and with symptoms of obsessive thoughts and compulsive behaviors.
Individuals with generalized social anxiety disorder (GSAD) exhibit exaggerated amygdala reactivity to aversive social stimuli. These findings could be explained by microstructural abnormalities in white matter (WM) tracts that connect the amygdala and prefrontal cortex, which is known to modulate the amygdala's response to threat. The goal of this study was to investigate brain frontal WM abnormalities using diffusion tensor imaging (DTI) in patients with social anxiety disorder.
A Turboprop DTI sequence was used to acquire diffusion tensor images in 30 patients with GSAD and 30 matched healthy control subjects. Fractional anisotropy, an index of axonal organization, within WM was quantified in individual subjects, and an automated voxel-based, whole-brain method was used to analyze group differences.
Compared with healthy control subjects, patients had significantly lower fractional anisotropy localized to the right uncinate fasciculus WM near the orbitofrontal cortex. There were no areas of higher fractional anisotropy in patients than controls.
These findings point to an abnormality in the uncinate fasciculus, the major WM tract connecting the frontal cortex to the amygdala and other limbic temporal regions, in GSAD, which could underlie the aberrant amygdala-prefrontal interactions resulting in dysfunctional social threat processing in this illness.
Body dysmorphic disorder (BDD) is a severe psychiatric condition in which individuals are preoccupied with perceived defects in their appearance. Little is known of the pathophysiology or neurobiology of BDD. Recent evidence from a functional MRI study examining visual processing of faces demonstrated abnormal activation patterns in regions including left-sided inferior frontal gyrus (IFG) and amygdala. To investigate morphometric abnormalities, we compared brain volumes from high-resolution T1 magnetic resonance images of 12 unmedicated subjects with BDD to images of 12 matched controls using voxel-based morphometry (VBM). In addition, we compared volumes in specific regions of interest including the IFG, amygdala, caudate, and total grey and white matter and examined correlations with symptom severity. VBM revealed no statistically significant volumetric differences, nor were there significant differences in any of the regions of interest. However, there were significant positive correlations between scores on the BDD version of the Yale-Brown Obsessive-Compulsive Disorder Scale (BDD-YBOCS) and volumes of the left IFG (r=0.69) and the right amygdala (r=0.54). These findings of correlations between BDD symptom severity and volumes of the left IFG and the right amygdala. These are in concordance with the involvement of these regions in pathological face processing, which may contribute to the primary symptomatology.
Abnormalities in white matter (WM) brain regions are attributed as a possible biomarker for schizophrenia (SZ). Diffusion tensor imaging (DTI) is used to capture WM tracts. Psychometric tests that evaluate the severity of symptoms of SZ are clinically used in the diagnosis process. In this study we investigate the correlates of scalar DTI measures, such as fractional anisotropy, mean diffusivity, axial diffusivity, and radial diffusivity with behavioral test scores. The correlations were found by different schemes: mean correlation with WM atlas regions and multiple regression of DTI values with test scores. The corpus callosum, superior longitudinal fasciculus right and inferior longitudinal fasciculus left were found to be having high correlations with test scores.
Diffusion weighted magnetic resonance imaging is a powerful tool that can be employed to study white matter microstructure by examining the 3D displacement profile of water molecules in brain tissue. By applying diffusion-sensitized gradients along a minimum of six directions, second-order tensors (represented by three-by-three positive definite matrices) can be computed to model dominant diffusion processes. However, conventional DTI is not sufficient to resolve more complicated white matter configurations, e.g., crossing fiber tracts. Recently, a number of high-angular resolution schemes with more than six gradient directions have been employed to address this issue. In this article, we introduce the tensor distribution function (TDF), a probability function defined on the space of symmetric positive definite matrices. Using the calculus of variations, we solve the TDF that optimally describes the observed data. Here, fiber crossing is modeled as an ensemble of Gaussian diffusion processes with weights specified by the TDF. Once this optimal TDF is determined, the orientation distribution function (ODF) can easily be computed by analytic integration of the resulting displacement probability function. Moreover, a tensor orientation distribution function (TOD) may also be derived from the TDF, allowing for the estimation of principal fiber directions and their corresponding eigenvalues.
The brain relies on interhemispheric communication for coherent integration of cognition and behavior. Surgical disconnection of the two cerebral hemispheres has granted numerous insights into the functional organization of the corpus callosum (CC) and its relationship to hemispheric specialization. Today, technologies exist that allow us to examine the healthy, intact brain to explore the ways in which callosal organization relates to normal cognitive functioning and cerebral lateralization. The CC is organized in a topographical manner along its antero-posterior axis. Evidence from neuroimaging studies is revealing with greater specificity the function and the cortical projection targets of the topographically organized callosal subregions. The size, myelination and density of fibers in callosal subregions are related to function of the brain regions they connect: smaller fibers are slow-conducting and connect higher-order association areas; larger fibers are fast-conducting and connect visual, motor and secondary somotosensory areas. A decrease in fiber size and transcallosal connectivity might be related to a reduced need for interhemispheric communication due, in part, to increased intrahemispheric connectivity and specialization. Additionally, it has been suggested that lateralization of function seen in the human brain lies along an evolutionary continuum. Hemispheric specialization reduces duplication of function between the hemispheres. The microstructure and connectivity patterns of the CC provide a window for understanding the evolution of hemispheric asymmetries and lateralization of function. Here, we review the ways in which converging methodologies are advancing our understanding of interhemispheric communication in the normal human brain.
The need for a simply applied quantitative assessment of handedness is discussed and some previous forms reviewed. An inventory of 20 items with a set of instructions and response- and computational-conventions is proposed and the results obtained from a young adult population numbering some 1100 individuals are reported. The separate items are examined from the point of view of sex, cultural and socio-economic factors which might appertain to them and also of their inter-relationship to each other and to the measure computed from them all. Criteria derived from these considerations are then applied to eliminate 10 of the original 20 items and the results recomputed to provide frequency-distribution and cumulative frequency functions and a revised item-analysis. The difference of incidence of handedness between the sexes is discussed.
A controversial issue that was debated for DSM-IV is whether body dysmorphic disorder (BDD)--a preoccupation with an imagined defect in appearance--can be psychotic. BDD is classified separately from its delusional counterpart (delusional disorder, somatic type) in DSM-IV, but does it have a psychotic variant that overlaps with, and may even be the same diagnostic entity as, its delusional disorder variant? One hundred consecutive patients with DSM-III-R-defined BDD or its delusional variant were assessed with a semistructured interview, the Structured Clinical Inverview for DSM-III-R, and a modified version of the Yale-Brown Obsessive Compulsive Scale (Y-BOCS). The 48 patients with nondelusional BDD were compared with the 52 patients with delusional BDD (i.e., delusional disorder, somatic type). The two groups did not differ significantly in terms of most variables examined, including demographics, phenomenology, course, associated features, comorbidity, and treatment response. Thus, BDD may have a psychotic subtype that significantly overlaps with, and may even be the same disorder as, its delusional disorder variant. However, delusional subjects had higher total scores on the modified Y-BOCS, suggesting that the delusional variant of BDD may be a more severe form of the disorder. Although preliminary, these findings have implications for BDD's treatment and classification, suggesting that inclusion of a delusional (psychotic) subtype of BDD should be considered for future editions of DSM.
Body dysmorphic disorder, preoccupation with an imagined defect in appearance, is included in DSM-III-R but has received little empirical study. The authors investigated the demographics, phenomenology, course, associated psychopathology, family history, and response to treatment in a series of 30 patients with the disorder.
The patients (including 12 whose preoccupation was of probable delusional intensity) were assessed with a semistructured interview and the Structural Clinical Interview for DSM-III-R, and their family histories were obtained.
The 17 men and 13 women reported a lifetime average of four bodily preoccupations, most commonly "defects" of the hair, nose, and skin. The average age at onset of body dysmorphic disorder was 15 years, and the average duration was 18 years. Seventy-three percent of the patients reported associated ideas or delusions of reference; 73%, excessive mirror checking; and 63%, attempts to camouflage their "deformities." As a result of their symptoms, 97% avoided usual social and occupational activities, 30% had been housebound, and 17% had made suicide attempts. Ninety-three percent of the patients had an associated lifetime diagnosis of a major mood disorder; 33%, a psychotic disorder; and 73%, an anxiety disorder. The patients generally responded poorly to surgical, dermatologic, and dental treatments and to adequate trials of most psychotropic medications, with the exception of fluoxetine and clomipramine (to which more than half had a complete or partial response).
This often secret, chronic disorder can cause considerable distress and impairment, may be related to obsessive-compulsive disorder or mood disorder, and may respond to serotonin reuptake-blocking antidepressants.