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Visual Information Processing of Faces in Body Dysmorphic Disorder

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Visual Information Processing of Faces in Body Dysmorphic Disorder ORIGINAL ARTICLE Visual Information Processing of Faces in Body Dysmorphic Disorder Jamie D. Feusner, MD; Jennifer Townsend; Alexander Bystritsky, MD; Susan Bookheimer, PhD Context: Body dysmorphic disorder (BDD) is a severe psy- Main Outcome Measure: Blood oxygen level– chiatric condition in which individuals are preoccupied with dependent functional magnetic resonance imaging sig- perceived appearance defects. Clinical observation sug- nal changes in the BDD and control groups during tasks gests that patients with BDD focus on details of their ap- with each stimulus type. pearance at the expense of configural elements. This study examines abnormalities in visual information processing Results: Subjects with BDD showed greater left hemi- in BDD that may underlie clinical symptoms. sphere activity relative to controls, particularly in lat- eral prefrontal cortex and lateral temporal lobe regions Objective: To determine whether patients with BDD for all face tasks (and dorsal anterior cingulate activity have abnormal patterns of brain activation when visu- for the low spatial frequency task). Controls recruited left- ally processing others’ faces with high, low, or normal sided prefrontal and dorsal anterior cingulate activity only spatial frequency information. for the high spatial frequency task. Design: Case-control study. Conclusions: Subjects with BDD demonstrate funda- mental differences from controls in visually processing Setting: University hospital. others’ faces. The predominance of left-sided activity for Participants: Twelve right-handed, medication-free sub- low spatial frequency and normal faces suggests detail jects with BDD and 13 control subjects matched by age, encoding and analysis rather than holistic processing, a sex, and educational achievement. pattern evident in controls only for high spatial fre- quency faces. These abnormalities may be associated with Intervention: Functional magnetic resonance imaging apparent perceptual distortions in patients with BDD. The while performing matching tasks of face stimuli. Stimuli fact that these findings occurred while subjects viewed were neutral-expression photographs of others’ faces that others’ faces suggests differences in visual processing be- were unaltered, altered to include only high spatial fre- yond distortions of their own appearance. quency visual information, or altered to include only low spatial frequency visual information. Arch Gen Psychiatry. 2007;64(12):1417-1426 ODY DYSMORPHIC DISORDER ology of BDD. To our knowledge, only 2 (BDD) is a severe psychiat- brain imaging studies of BDD have been ric condition in which pa- published. A volumetric magnetic reso- tients are preoccupied with nance imaging study3 found leftward shift perceived physical defects. in caudate asymmetry and greater total BThis causes them to believe that they ap- white matter volume in 8 women with pear disfigured and ugly. They subse- BDD compared with 8 female control sub- quently experience significant distress, dis- jects, opposite to typical findings in ob- ability, and functional impairment, often sessive-compulsive disorder (OCD).4,5 accompanied by severe depression and sui- Using single-photon emission computed Author Affiliations: cidality.1 Body dysmorphic disorder likely tomography, a small functional imaging Department of Psychiatry and affects about 1.7% of the population2 yet study6 of 6 patients with BDD showed vari- Biobehavioral Sciences is understudied and underrecognized. able discrepant findings, including rela- (Drs Feusner and Bystritsky) A better understanding of the neuro- tive perfusion deficits in bilateral antero- and Center for Cognitive Neuroscience (Ms Townsend biology of BDD could assist in elucidat- medial temporal and occipital regions and and Dr Bookheimer), David ing the pathophysiology underlying the asymmetric perfusion in parietal lobes. Al- Geffen School of Medicine at clinical symptoms. This, in turn, can help though this study had no control or com- the University of California, improve strategies for clinical manage- parison group, the findings suggest the Los Angeles. ment. Little is known about the neurobi- possibility of abnormalities in brain re- (REPRINTED) ARCH GEN PSYCHIATRY/ VOL 64 (NO. 12), DEC 2007 WWW.ARCHGENPSYCHIATRY.COM 1417 ©2007 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 NSF LSF HSF Figure 1. Face stimuli. HSF indicates high spatial frequency; LSF, low spatial frequency; and NSF, normal spatial frequency. (On reproduction, the HSF image in this figure lost some of the detail that was visible in the experiment.) + HSF LSF NSF Control Task × 4 20 4 1 1 Interval, s Figure 2. Blocked design for the presentation of face and control stimuli. HSF indicates high spatial frequency; LSF, low spatial frequency; and NSF, normal spatial frequency. Between subjects, differently ordered runs were counterbalanced using a Latin square design. gions involved in visual processing and visuospatial findings from this neuropsychological study suggest that functioning. patients with BDD may have aberrant visual information Clinically, patients with BDD most often perceive “de- processing. If so, this may represent a core pathophysi- fects” of their face and head areas.7 They tend to fre- ological process contributing to the symptoms. quently check their appearance in mirrors and often scru- Evidence also suggests that individuals with BDD may tinize others’ faces. Clinical observation suggests that have abnormalities in face processing. In a study9 that patients with BDD focus primarily on details, usually their presented computerized images of their own faces to sub- face, at the expense of global or configural aspects. A neu- jects with BDD, subjects with OCD, and healthy control ropsychological study8 using the Rey-Osterrieth Complex subjects, half of the BDD and OCD groups but none of Figure Copy and Delayed Recall Test demonstrated that the controls perceived distortions that were not actually patients with BDD performed poorly relative to controls present. There is also evidence of abnormal processing because of differences in organizational strategies, includ- of emotional faces in BDD. Buhlmann et al10 examined ing selective recall of details instead of larger organiza- how patients with BDD interpret facial expressions com- tional design features. The phenomenology of BDD and the pared with healthy controls and a group having OCD. (REPRINTED) ARCH GEN PSYCHIATRY/ VOL 64 (NO. 12), DEC 2007 WWW.ARCHGENPSYCHIATRY.COM 1418 ©2007 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 There were no differences in accuracy between groups visual pathways, as reflected by their apparent visual in general facial feature recognition for neutral- bias for high levels of detail. expression faces. However, individuals with BDD had dif- ficulty interpreting facial expressions, more often mis- METHODS identifying faces as being angry. Although this may indicate abnormalities specifically in emotional recog- nition, it may also reflect abnormalities in an earlier com- SUBJECTS ponent of the core system for visual analysis that is re- quired for facial expression analysis.11,12 The UCLA Institutional Review Board approved the protocol Face perception in healthy control subjects seems to be for the study. We obtained informed consent from 12 subjects with BDD and 13 healthy control subjects (age range, 18-64 mediated by multiple regions in the extrastriate visual cor- years) recruited from the community. The BDD group and con- tex and other nonvisual cortex regions that form a distrib- trols were matched by sex, age, and educational achievement. 11 uted network. The inferior occipital gyri, responsible for All participants were right-handed. All subjects with BDD met early perception of facial features, provides input to the su- DSM-IV criteria for BDD using the Body Dysmorphic Disorder perior temporal sulcus (changeable aspects of faces such Module,29 a reliable diagnostic module modeled after the Struc- as expressions) and the lateral fusiform gyrus (invariant as- tured Clinical Interview for DSM. In addition, we performed a pects of faces).11,12 Functional neuroimaging of face- clinical psychiatric evaluation of all participants and screened matching tasks has demonstrated activity in the ventral oc- them using the Mini-International Neuropsychiatric Inter- 30 cipitotemporal and dorsolateral occipitoparietal cortices, view. All subjects with BDD were required to have a score of as well as prefrontal and temporal regions.13-15 at least 15 on the BDD version of the Yale-Brown Obsessive Com- pulsive Scale (BDD-YBOCS).31 We allowed subjects with de- This study aimed to determine whether patients with lusional beliefs. BDD have a different pattern of brain activation from that Exclusion criteria for subjects and controls included preg- of healthy control subjects for different spatial frequen- nancy, active substance abuse, current neurological disorder, cies when viewing faces. Using others’ faces rather than their and any current medical disorder that may affect cerebral me- own allows for testing of primary visual processing abnor- tabolism. We excluded subjects with any concurrent Axis I dis- malities while minimizing the influence of distorted self- order other than dysthymia, major depressive disorder, or gen- representations and symptom provocation. To our knowl- eralized anxiety disorder. Because depression and anxiety are
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