The effects of a retrieval cue on renewal of conditioned responses in human appetitive conditioning.

Contextual renewal of reward anticipation may be one potential mechanism underlying relapse in eating and substance use disorders. We therefore tested retrieval cues, a method derived from an inhibitory retrieval-based model of extinction learning to attenuate contextual renewal using an appetitive conditioning paradigm. A pilot study was carried out in Experiment 1 to validate a differential chocolate conditioning paradigm, in which a specific tray was set up as a conditioned stimulus (CS) for eating chocolate (unconditioned stimulus, US). Using an ABA renewal design in Experiment 2, half of the participants were presented with a retrieval cue in the acquisition phase (group AC) and the other half in the extinction phase (group EC). Presentation of the retrieval cue in the EC was associated with reduced renewal of US-expectancy, while there was a clear renewal effect for US-expectancy in the AC. One limitation was the difference in cue presentations between both groups due to the number of trials in acquisition and extinction. Experiment 3 therefore aimed at replicating the results of Experiment 2, but with fewer cue presentations for the EC to match the AC. No significant group differences were observed indicating no effect of the retrieval cue. Theoretical and clinical implications in light of the differing results are discussed.

Implicit approach-avoidance tendencies toward food and body stimuli absent in individuals with anorexia nervosa, bulimia nervosa, and healthy controls.

OBJECTIVE: Body and food-related information are thought to activate cognitive biases and contribute to the maintenance of eating disorders (ED). Approach-avoidance biases may play an important role in the maintenance of dietary restriction and excessive food intake. Therefore, the present study aimed to examine approach-avoidance biases toward food and body stimuli in individuals with anorexia nervosa (AN), bulimia nervosa (BN), and healthy controls (HC). METHODS: The study included 42 individuals with AN, 24 individuals with BN, and 38 HCs. We used two implicit Approach-Avoidance Tasks (AAT) to assess approach-avoidance biases: participants completed a Food-AAT (high-calorie vs. low-calorie food) and a Body-AAT (thin vs. normal weight bodies). Additionally, explicit ratings of food and body stimuli were assessed. RESULTS: There were no significant Group × Stimulus × Direction interactions in the implicit Food-AAT or implicit Body-AAT. In explicit ratings, individuals with AN and BN reported less urge to eat and more regret if they ate high-calorie and low-calorie food; individuals with AN and BN rated normal weight bodies as less normal weight, less attractive and less desirable than HCs. There were no group differences in explicit ratings of the thin body. DISCUSSION: We did not find evidence for biased approach-avoidance tendencies toward food or body stimuli in individuals with AN or BN. Future studies are necessary to understand conflicting findings regarding approach-avoidance biases toward food and body stimuli in individuals with ED.

An empirically derived recommendation for the classification of body dysmorphic disorder: Findings from structural equation modeling.

Body dysmorphic disorder (BDD), together with its subtype muscle dysmorphia (MD), has been relocated from the Somatoform Disorders category in the DSM-IV to the newly created Obsessive-Compulsive and Related Disorders category in the DSM-5. Both categorizations have been criticized, and an empirically derived classification of BDD is lacking. A community sample of N = 736 participants completed an online survey assessing different psychopathologies. Using a structural equation modeling approach, six theoretically derived models, which differed in their allocation of BDD symptoms to various factors (i.e. general psychopathology, somatoform, obsessive-compulsive and related disorders, affective, body image, and BDD model) were tested in the full sample and in a restricted sample (n = 465) which indicated primary concerns other than shape and weight. Furthermore, measurement invariance across gender was examined. Of the six models, only the body image model showed a good fit (CFI = 0.972, RMSEA = 0.049, SRMR = 0.027, TLI = 0.959), and yielded better AIC and BIC indices than the competing models. Analyses in the restricted sample replicated these findings. Analyses of measurement invariance of the body image model showed partial metric invariance across gender. The findings suggest that a body image model provides the best fit for the classification of BDD and MD. This is in line with previous studies showing strong similarities between eating disorders and BDD, including MD. Measurement invariance across gender indicates a comparable presentation and comorbid structure of BDD in males and females, which also corresponds to the equal prevalence rates of BDD across gender.

Approach and avoidance: Relations with the thin body ideal in women with disordered eating behavior.

Recent research suggests that automatic cognitive biases are linked to body dissatisfaction and disordered eating behavior. However, little is known about automatic action tendencies in the field of body image research. The aim of the present study was to examine approach and avoidance biases toward the thin body ideal and normal weight bodies and whether these are pronounced in individuals showing disordered eating behavior. Participants were divided into a group with disordered eating behavior (n = 55) and without disordered eating behavior (n = 45). To assess approach and avoidance tendencies, the Approach-Avoidance Task was used during which the participants were instructed to approach or avoid thin and normal weight body pictures. Our results indicated faster push than pull movements towards thin and normal weight body pictures. However, participants with and without disordered eating behavior did not differ with regard to their reactions. Furthermore, we found positive associations between the avoidance of normal weight body pictures and perceived pressure to confirm to media ideals. Future research is warranted to replicate our findings and to extend our knowledge on approach and avoidance biases toward body pictures in patients suffering from eating disorders.

The Dysmorphic Concern Questionnaire in the German General Population: Psychometric Properties and Normative Data.

BACKGROUND: The Dysmorphic Concern Questionnaire (DCQ) is a widely used screening instrument assessing dysmorphic concerns ranging from a mild to an excessive level. It is often used in the setting of plastic and aesthetic surgery. The present study aimed at examining the psychometric properties of the DCQ in a random general population sample. METHODS: A representative sample of the German general population (N = 2053, aged between 18 and 65 years, 54% females) completed the DCQ as well as questionnaires on depression and appearance concerns. RESULTS: The DCQ showed a good internal consistency with Cronbach's α = 0.81. Its one-factor model structure was confirmed. Normative data were stratified according to gender and age. Women reported more dysmorphic concerns than men, but also within females the DCQ scores differed between age classes. Overall, 4.0% of the sample reported excessive dysmorphic concerns based on a previously defined cutoff sum score ≥ 11. CONCLUSION: The DCQ is a valid and reliable screening tool to identify individuals with excessive dysmorphic concerns. Excessive concerns may indicate also the presence of body dysmorphic disorder, but for verifying a final diagnosis the use of a structured clinical interview is necessary. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Pavlovian-to-instrumental transfer: A new paradigm to assess pathological mechanisms with regard to the use of Internet applications.

At present, there is a considerable lack of human studies that investigated the impact of conditioned cues on instrumental responding although these processes are considered as core mechanisms contributing to the development and maintenance of addictive behaviours. No studies are available that assessed these processes with regard to Internet gaming or Internet shopping applications. We thus developed a Pavlovian-to-instrumental transfer (PIT)-Paradigm implementing appetitive stimuli related to Internet gaming and Internet shopping applications and investigated whether an outcome-specific PIT-Effect is observed. In addition, we assessed whether the problematic use of gaming or shopping applications, personality traits and stress would affect the acquisition of knowledge of the experimental contingencies during Pavlovian training and the impact of conditioned stimuli on instrumental responding. A PIT-Paradigm, screenings for Internet gaming disorder and Internet shopping disorder (s-IAT), and questionnaires on personality traits (NEO-FFI, BIS-15) and perceived stress (PSQ20) were administered to sixty-six participants. The PIT-Paradigm demonstrated the effects of stimuli conditioned to rewards related to Internet gaming and Internet shopping applications on instrumental responding to obtain such rewards. Findings also indicated that severity of problematic Internet gaming, but not Internet shopping, contributed to the acquisition of knowledge of the experimental contingencies. Stress, extraversion, neuroticism and gender emerged as further predictors. The strength of expectancy of the different reinforcers affected the 'gaming PIT'-Effect; however, none of the variables assessed in the present study showed any effect on the 'shopping PIT'-Effect. Future studies including participants with pathological use patterns that can be classified as internet use disorder are warranted to extend these findings.

Cognitive control functions in individuals with obesity with and without binge-eating disorder.

OBJECTIVE: Deficits in cognitive control are thought to contribute to the maintenance of obesity (OB). Cognitive control is referred to as impulsivity and binge-eating disorder (BED) is characterized by high levels of impulsivity. The present study sought to elucidate which cognitive control functions differentiate between severe OB with and without BED also taking into account hunger as a moderating factor. METHOD: The study included 48 individuals with OB and BED (OB + BED), 48 individuals with OB and no BED (OB - BED) and 48 normal-weight controls (NWC). Hunger was systematically manipulated: participants were instructed to refrain from eating before testing and received either a liquid meal or flavored water. Then, a comprehensive test battery was administered including a food-related go/no-go task and several subtests from the CANTAB. RESULTS: There were no differences between the groups with regard to food-related response inhibition. However, while manipulating hunger had no impact on performance in the go/no-go task, self-reported hunger significantly influenced task performance by increasing inhibition deficits to high-caloric stimuli in OB + BED. With regard to general cognitive control functions, we found that deficits in attention and impulse control in decision-making distinguished OB from NWC, while reversal learning and risk taking in decision-making appeared to be relevant factors when distinguishing OB + BED from OB - BED. DISCUSSION: Our results indicate that self-reported hunger differentially affected food-related response inhibition. Group differences in general cognitive control functions were limited to attention, reversal learning, and decision-making. Future research needs to account for other possible moderating factors, such as mood, food craving, or stress.

An app-based blended intervention to reduce body dissatisfaction: A randomized controlled pilot study.

OBJECTIVE: As a common experience in the general population, dissatisfaction with one's body is associated with a variety of psychological problems and unhealthy behaviors, including the development of eating disorders. Therefore, the purpose of the present study was to develop and evaluate an app-based intervention to reduce body dissatisfaction. METHOD: Participants reporting elevated levels of body dissatisfaction were randomly allocated to an app-based intervention (n = 26) or to a wait list group (n = 27). The app-based intervention included a brief counseling session and 14 days of training with the Mindtastic Body Dissatisfaction app (MT-BD). The MT-BD app uses gamification strategies to systematically foster approach of functional and avoidance of dysfunctional stimuli. The primary outcome was body dissatisfaction as assessed with the Body Dissatisfaction scale of the Eating Disorder Inventory-2 (Garner, 1991). Secondary outcome measures included severity of eating disorder symptoms and depressive symptoms. RESULTS: Participants in the intervention group showed significantly greater reductions in body dissatisfaction compared to the wait list group (d = -0.62). The intervention group also showed greater reductions in eating disorder symptoms compared to the wait list group (d = -0.46). Reductions in body dissatisfaction and eating disorder symptoms were sustained at a 1-month follow-up. CONCLUSION: We found preliminary evidence that an app-based intervention may significantly reduce body dissatisfaction. Further research using larger samples and targeting clinical populations is necessary to evaluate the potential of interventions such as MT-BD. (PsycINFO Database Record

Visual selective attention in body dysmorphic disorder, bulimia nervosa and healthy controls.

OBJECTIVE: Cognitive behavioral models postulate that selective attention plays an important role in the maintenance of body dysmorphic disorder (BDD). It is suggested that individuals with BDD overfocus on perceived defects in their appearance, which may contribute to the excessive preoccupation with their appearance. METHODS: The present study used eye tracking to examine visual selective attention in individuals with BDD (n=19), as compared to individuals with bulimia nervosa (BN) (n=21) and healthy controls (HCs) (n=21). Participants completed interviews, questionnaires, rating scales and an eye tracking task: Eye movements were recorded while participants viewed photographs of their own face and attractive as well as unattractive other faces. RESULTS: Eye tracking data showed that BDD and BN participants focused less on their self-rated most attractive facial part than HCs. Scanning patterns in own and other faces showed that BDD and BN participants paid as much attention to attractive as to unattractive features in their own face, whereas they focused more on attractive features in attractive other faces. HCs paid more attention to attractive features in their own face and did the same in attractive other faces. CONCLUSION: Results indicate an attentional bias in BDD and BN participants manifesting itself in a neglect of positive features compared to HCs. Perceptual retraining may be an important aspect to focus on in therapy in order to overcome the neglect of positive facial aspects. Future research should aim to disentangle attentional processes in BDD by examining the time course of attentional processing.

Classification of body dysmorphic disorder - what is the advantage of the new DSM-5 criteria?

OBJECTIVE: In DSM-5 the diagnosis of body dysmorphic disorder (BDD) has been subjected to two important changes: Firstly, BDD has been assigned to the category of obsessive-compulsive and related disorders. Secondly, a new criterion has been defined requiring the presence of repetitive behaviors or mental acts in response to appearance concerns. The aims of this study were to report the prevalence rates of BDD based on a DSM-5 diagnosis, and to evaluate the impact of the recently introduced DSM-5 criteria for BDD by comparing the prevalence rates (DSM-5 vs. DSM-IV) METHODS: BDD-criteria (DSM-IV/DSM-5), dysmorphic concerns, and depressive symptoms, were assessed in a representative sample of the German general population (N=2129, aged 18-65years). RESULTS: The association between BDD case identification based on DSM-IV and DSM-5 was strong (Phi=.95, p<.001), although point prevalence of BDD according to DSM-5 was slightly lower (2.9%, n=62 vs. 3.2%, n=68). Approximately one third of the identified BDD (DSM-5) cases reported time-consuming behavioral acts in response to appearance concerns. In detail, 0.8% of the German general population fulfilled the BDD criteria and reported repetitive acts of at least one hour/day. CONCLUSIONS: The revised criteria of BDD in DSM-5 do not seem to have an impact on prevalence rates. However, the recently added B-criterion reflects more precisely the clinical symptoms of BDD, and may be useful for distinguishing between various severity levels related to repetitive behaviors/mental acts.

Body-related cognitions, affect and post-event processing in body dysmorphic disorder.

BACKGROUND AND OBJECTIVES: Cognitive behavioural models postulate that individuals with BDD engage in negative appearance-related appraisals and affect. External representations of one's appearance are thought to activate a specific mode of processing characterized by increased self-focused attention and an activation of negative appraisals and affect. METHODS: The present study used a think-aloud approach including an in vivo body exposure to examine body-related cognitions and affect in individuals with BDD (n = 30), as compared to individuals with major depression (n = 30) and healthy controls (n = 30). Participants were instructed to think aloud during baseline, exposure and follow-up trials. RESULTS: Individuals with BDD verbalized more body-related and more negative body-related cognitions during all trials and reported higher degrees of negative affect than both control groups. A weaker increase of positive body-related cognitions during exposure, a stronger increase of sadness and anger after exposure and higher levels of post-event processing, were specific processes in individuals with BDD. LIMITATIONS: Individuals with major depression were not excluded from the BDD group. This is associated with a reduction of internal validity, as the two clinical groups are somewhat interwoven. Key findings need to be replicated. CONCLUSION: The findings indicate that outcomes such as negative appearance-related cognitions and affect are specific to individuals with BDD. An external representation of one's appearance activates a specific mode of processing in BDD, manifesting itself in the absence of positive body-related cognitions, increased anger and sadness, and high levels of post-event processing. These specific processes may contribute toward maintenance of BDD psychopathology.

Personality traits as vulnerability factors in body dysmorphic disorder.

Cognitive behavioural models consider certain personality traits to be risk factors for the development of Body Dysmorphic Disorder (BDD). Research on personality traits in BDD is scarce, therefore this study examined perfectionism, aesthetic sensitivity and the behavioural inhibition system (BIS) in BDD. Furthermore, the association between these personality traits and the extent of dysmorphic concerns was investigated. Individuals with BDD (n=58) and a population based control sample (n=2071), selected from a representative German population survey, completed self-report questionnaires assessing DSM-5 criteria of BDD, dysmorphic concerns, perfectionism, aesthetic sensitivity and BIS-reactivity. Individuals with BDD reported significantly higher degrees of perfectionism as well as of BIS-reactivity compared to the population based control sample, whereas the groups did not differ significantly regarding aesthetic sensitivity. However, for the total sample, each of the personality traits was related dimensionally to dysmorphic concerns. Current BDD models consider perfectionism and aesthetic sensitivity to be vulnerability factors. In addition to these concepts, the present study suggests that BIS-reactivity is related to BDD. Self-reported aesthetic sensitivity was not found to be specifically pronounced in BDD, but along with perfectionism and BIS-reactivity aesthetic sensitivity was generally associated with dysmorphic concerns.

Body dysmorphic disorder and nonweight-related body image concerns in individuals with eating disorders.

OBJECTIVE: Research on the prevalence of body dysmorphic disorder (BDD) in individuals with eating disorders (EDs) is scarce. Nonweight-related appearance concerns, which can be considered as variants of BDD concerns, have also rarely been examined in EDs. This study therefore investigates BDD prevalence and nonweight-related appearance concerns in EDs. METHOD: One hundred individuals with EDs (49 inpatients with anorexia nervosa, 51 inpatients with bulimia nervosa) completed structured diagnostic interviews and self-report questionnaires. RESULTS: Twelve individuals with EDs (12.0%) suffered from comorbid BDD, with their body dysmorphic concerns being unrelated to weight and shape. BDD lifetime-prevalence was 15.0%. There was a high prevalence of dissatisfaction with nonweight-related body features such as skin, hair, teeth, nose, and height (20.8 to 53.5%). DISCUSSION: Findings indicate that BDD is a frequent comorbid disorder in individuals with EDs. Furthermore, along with weight and body shape, nonweight-related appearance concerns are also common in individuals with EDs.

Body image, emotions and thought control strategies in body dysmorphic disorder compared to eating disorders and healthy controls.

OBJECTIVE: A disordered body image, emotions such as shame and disgust, and intrusive thoughts are described as important and interdependent features of body dysmorphic disorder (BDD). However, research in this field is scarce and knowledge is often based on clinical observation. METHODS: The present study examined body image dimensions, emotions, and thought control strategies in individuals with: BDD (n=31), anorexia nervosa (n=32), bulimia nervosa (n=34), and healthy controls (n=33). Assessment was based on structured diagnostic interviews and self-report questionnaires. RESULTS: Individuals with BDD scored higher on psychosocial and appearance manipulation dimensions of body image compared to healthy controls. Furthermore, they reported higher psychosocial impairment due to appearance than both eating disorder groups. In terms of emotions, BDD subjects reported a higher degree of negative emotions compared to healthy controls, whereas no differences were found in comparison to eating-disordered patients. Individuals with BDD reported using maladaptive strategies such as worrying and confrontation more often than healthy controls, when encountering intrusive and unwanted thoughts. CONCLUSION: The results indicate that individuals with BDD experience substantial psychosocial impairment due to appearance, high levels of various negative emotions and frequently use maladaptive thought control strategies.

Impulse control disorders in psychiatric inpatients.

The aim of this study was to examine the prevalence of impulse control disorders (ICDs) in a European psychiatric inpatient sample. Two hundred thirty four consecutive psychiatric inpatients (62% female) were examined using a module of the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders fourth edition (DSM-IV) that has been developed for ICDs (SCID-ICD). In addition to intermittent explosive disorder, pyromania, kleptomania, pathological gambling, and trichotillomania, the proposed ICDs not otherwise specified were assessed, including compulsive buying, nonparaphilic compulsive sexual behavior, pathological internet use, and pathological skin picking. Based on the SCID-ICD, a lifetime ICD rate of 23.5% and a current ICD rate of 18.8% were found. The most frequent ICDs were pathological skin picking (lifetime 7.3%, current 6.8%), compulsive buying (lifetime 6.8%, current 6.0%), and intermittent explosive disorder (lifetime 5.6%, current 3.4%). In contrast, referring to admission diagnoses taken from patients' charts only 3.8% of the inpatients were diagnosed with any current ICD. Individuals with comorbid ICD were significantly younger and had more admission diagnoses other than ICD. The results suggest high rates of ICDs among psychiatric inpatients that remain to be under-diagnosed in clinical routine.

Prevalence of body dysmorphic disorder in a German psychiatric inpatient sample.

Body dysmorphic disorder (BDD) is a distressing or impairing preoccupation with an imagined or slight defect in appearance. Only a few studies have examined BDD prevalence in psychiatric settings. Prevalence rates vary widely and most studies have been conducted in outpatient samples. In the current study, we examined 155 adult psychiatric inpatients. Diagnostic criteria of BDD were assessed with the BDD module of the Structured Clinical Interview for DSM-IV. The prevalence of lifetime BDD was 2.6% (95% CI=0.1-5.1%). Currently 1.9% of the patients suffered from BDD (95% CI=0.0-4.0%). None of these patients were diagnosed with BDD on admission or during hospitalization. The BDD rates found in this study are considerably lower than lifetime and current prevalence rates reported by two other studies conducted in adult psychiatric inpatient settings (Grant et al., 2001; Conroy et al., 2008). The differences may be explained by divergent sample compositions and variation in diagnostic measures. The findings of the current study underline the need for further studies examining BDD prevalence in psychiatric settings and suggest using a combination of screening questionnaire and follow-up interview to diagnose BDD.