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Cerea, Silvia (2017) The meaning of beauty: when the problem is with body image. Prevalence, clinical features, and at risk populations of Body Dysmorphic Disorder in the Italian context. [Ph.D. thesis]

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Abstract (english)

Body Dysmorphic Disorder (BDD) is a psychological disorder characterized by the persistent preoccupation with one or more perceived defects in physical appearance that are not observable or appear slight to others (American Psychiatric Association [APA], 2013), which is currently included into the “Obsessive-Compulsive and Related Disorders” category of the Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (DSM-5; APA, 2013). Although any body part can be the focus of concerns, the most common areas of concern in people with BDD are the skin (presence of acne or scars), the hair (hair loss, thinning, or excessive facial or body hair), and the nose (shape or size; Phillips 2006; Phillips & Diaz 1997; Phillips, McElroy, Keck, Pope, & Hudson, 1993; Veale et al., 1996), and individuals with BDD may be concerned with multiple body parts at the same time (Phillips et al., 1993; 2005). In response to the appearance concerns, individuals with BDD engage in repetitive and time-consuming behaviors and mental actions focused on examining, being reassured about, and hiding perceived defects (Phillips & Diaz, 1997; Phillips, Menard, Fay, & Weisberg, 2005). The most common are: camouflaging (e.g., with hair, makeup, body position, or sunglasses), checking the perceived defect in mirrors or other reflecting surfaces (e.g., windows), excessively grooming (e.g., applying makeup or styling hair), seeking reassurance from family and friends about the defect, repeatedly touching the disliked areas, and comparing one’s appearance with that of other people (Phillips, 2009; Phillips & Diaz, 1997; Phillips et al., 2005; Veale & Riley, 2001). Behaviors are unlimited (Phillips, 1998) and can include seeking plastic surgery or cosmetic medical treatments in order to reduce the perceived defects (Crerand, Phillips, Menard, & Fay, 2005; Phillips, Grant, Siniscalchi, & Albertini, 2001); these procedures, however, are not beneficial (Crerand et al., 2005; Phillips et al., 2001) and do not typically result in a decrease of BDD symptoms severity (Crerand et al., 2005; Phillips et al., 1993; Phillips et al., 2001). Rather, some patients with BDD experience symptoms exacerbation and development of new appearance concerns (Crerand et al., 2005; Phillips et al., 2001; Veale, 2000; Veale et al., 1996). In addition to core concerns about appearance, BDD is characterized by low self-esteem, high perfectionism, and high comorbidity rate (Phillips, 2006; Phillips et al., 1993; Phillips et al., 2005). The most common associated disorders are: Major Depressive Disorder (MDD), Social Anxiety Disorder (SAD), Obsessive Compulsive Disorder (OCD), and Anorexia Nervosa (AN; Dingemans, van Rood, de Groot, & van Furth, 2012; Grant, Kim, & Eckert, 2002; Gunstad & Phillips, 2003). Despite increased awareness of BDD in recent years, it continues to be an under-studied disorder (Buhlmann & Winter, 2011; Buhlmann et al., 2010), particularly in the Italian context. Indeed, little is known about BDD prevalence and phenomenology in Italy, and no data are available on BDD prevalence rates using DSM-5 criteria (APA, 2013) in the Italian general population. Therefore, the current dissertation aimed at assessing BDD prevalence, phenomenology, associated clinical features, and at risk populations through three studies.
The first study aimed at exploring the prevalence and the phenomenology of BDD in an Italian community sample and its associated clinical features such as self-esteem, perfectionistic traits, social anxiety, depressive, and obsessive-compulsive symptoms. Six hundred and fifteen community individuals completed a battery of self-report questionnaires assessing the above-mentioned clinical features. Results showed that 10 (1.63%) individuals met DSM-5 criteria (APA, 2013) for BDD. Hair (n = 4; 4%), nose (n = 4; 4%), and teeth (n = 4; 4%) were the most common areas of concern. With respect to the associated clinical features, individuals who satisfied BDD diagnostic criteria reported lower levels of self-esteem, more severe social anxiety symptomatology, general distress, depression, and obsessive-compulsive features than people without BDD. These findings outlined that, within the Italian context, BDD is a relatively common psychological disorder associated with significant morbidity.
The second study of the current dissertation focused on the shared clinical features between BDD and AN. Indeed, both the psychopathologies are severe body image disorders (Rosen, Reiter, & Orosan, 1995) characterized by body image disturbance and dissatisfaction, intrusive thoughts about appearance, and by an overemphasis on appearance in the evaluation of self-worth (Rosen & Ramirez, 1998). Furthermore, both BDD and AN are characterized by low self-esteem (Phillips, Pinto, & Jain, 2004; Rosen & Ramirez, 1998) and high levels of perfectionism (Bardone-Cone et al., 2007; Buhlmann, Etcoff, & Wilhelm, 2008; Bulik et al., 2003; Veale, 2004). Many studies underlined the high comorbidity between BDD and AN (Dingemans et al., 2012; Fenwick & Sullivan, 2011; Grant et al., 2002; Kollei, Schieber, Zwaan, Svitak, & Martin, 2013; Ruffolo, Phillips, Menard, Fay, & Weisberg, 2006), and patients with AN frequently report nonweight-related body image concerns (Dingemans et al., 2012; Grant et al., 2002; Kollei et al., 2013). Furthermore, patients with AN and comorbid BDD report greater body image dissatisfaction and clinical symptomatology than those without comorbid BDD (Dingemans et al., 2012; Grant et al., 2002). Therefore, the first aim of this study was to assess the prevalence of BDD and the presence of nonweight- related body image concerns in patients with AN. Secondly, the study aimed at comparing patients with AN and nonweight-related body image concerns, patients with weight-related body image concerns only and a healthy control group with respect to body image and psychological and psychopathological features. For these purposes, 61 patients with AN were divided in two groups: 39 with nonweight-related body image concerns and 22 with weight-related body image concerns only. Furthermore, a group of 61 healthy controls was recruited. Main results of this study showed that 16 (26.23%) patients with AN had probable comorbid BDD. The most common nonweight-related body image concerns were: hair (41.02%), nose (30.77%), skin (30.77%), teeth (25.64%), and height (20.51%). Moreover, patients with AN and nonweight-related body image concerns reported greater levels of psychopathology not related to eating disorder than patients with weight-related body image concerns only, in accordance with previous studies (Dingemans et al., 2012; Grant et al., 2002). In conclusion, patients with AN and nonweight-related body image concerns showed a more severe body image disturbance unrelated to a more severe eating disorder.
Lastly, the third study of the current dissertation aimed at assessing the prevalence of Muscle Dysmorphia (MD), its associated psychological features and possible predictors among 3 groups (N = 125) of Italian recreational athletes. MD is a subtype of BDD characterized by the preoccupation with the idea that one’s body is not sufficiently lean and muscular (APA, 2013; Pope, Gruber, Choi, Olivardia, & Phillips, 1997); however, individuals with MD have a normal-looking body or are even very muscular, much more than the average of people (Pope et al., 1997). The first aim of this study was to explore the prevalence and the phenomenology of MD in 3 groups of Italian participants who trained regularly for recreational purposes: 42 bodybuilders, 61 strength trainers, and 22 fitness wellness trainers. Secondly, we aimed at investigating MD related behaviours and psychological features such as self-esteem, perfectionistic traits, social anxiety and orthorexia nervosa symptoms, and general distress among groups. Lastly, we aimed at assessing the presence of associations between MD and related psychological features among the 3 groups and, with exploratory purposes, possible MD predictors among groups. Results revealed a MD prevalence of 6.4%: 4 participants (9.52%) in the bodybuilding group, 2 participants (3.28%) in the strength group, and 2 participants (9.09%) in the fitness/wellness group satisfied Pope et al. (1997) diagnostic criteria for MD. With respect to MD associated cognitive and behavioural symptoms, the bodybuilding group reported more frequently to think about taking anabolic- androgenic steroids (AAS), to assume more than 2 daily grams of proteins, and to experience more beliefs about being smaller and weaker than desired or wishes to be more muscular than the other groups, whereas this group reported more MD general symptomatology only with respect to the fitness/wellness group. Moreover, the strength group reported to set higher standards for themselves than the other two groups. Finally, different correlational patterns among group emerged, as well as different MD predictors. Specifically, social anxiety symptoms resulted significant predictors of MD symptomatology for both the bodybuilding and the strength group, whereas no predictors emerged for the fitness/wellness group. In conclusion, results of this study underlined that the pursuit of a lean and muscular physique in bodybuilding is not always associated with MD and related psychological features.
To conclude, this dissertation provides clinical hints as far as concern both preventive strategies and psychological treatment implications for BDD across at risk populations.

Abstract (italian)

Il Disturbo di Dismorfismo Corporeo (Body Dysmorphic Disorder; BDD) è un disturbo psicologico caratterizzato dalla persistente preoccupazione per la presenza di uno o più presunti difetti nell’aspetto fisico che, tuttavia, appaiono agli altri come lievi o non osservabili (American Psychiatric Association [APA], 2013). Attualmente il BDD è classificato all’interno della categoria diagnostica “Disturbo Ossessivo-Compulsivo e Disturbi Correlati” nella quinta edizione del Manuale Diagnostico e Statistico dei Disturbi Mentali (Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition [DSM-5], APA, 2013). Le aree del corpo maggiormente oggetto di preoccupazione nelle persone con BDD sono la pelle (presenza di acne o di cicatrici), i capelli (perdita di capelli, capelli fini o eccessiva peluria), e il naso (forma o dimensione; Phillips 2006; Phillips & Diaz 1997; Phillips, McElroy, Keck, Pope, & Hudson, 1993; Veale et al., 1996), nonostante ogni area del corpo possa rappresentare il focus della preoccupazione. Le persone con BDD, inoltre, possono essere preoccupate per difetti presenti in più aree del corpo contemporaneamente (Phillips et al., 1993; 2005). In risposta alle preoccupazioni per l’aspetto fisico, le persone con BDD mettono generalmente in atto comportamenti ripetitivi e azioni mentali volti a esaminare, cercare rassicurazioni e a nascondere i presunti difetti nell’aspetto fisico (Phillips & Diaz, 1997; Phillips, Menard, Fay, & Weisberg, 2005). Tra i più comuni rientrano il camuffamento (ad esempio, con il make-up, con le posizioni del corpo o con gli occhiali da sole), il controllo dei presunti difetti in specchi o in altre superfici riflettenti (ad esempio, nelle vetrine), l’eccessivo grooming (ad esempio, applicando ripetutamente make-up o attraverso le acconciature dei capelli), la ricerca di rassicurazione da parte di familiari e amici, il toccare ripetutamente le aree del corpo oggetto di preoccupazione e il confrontare il proprio aspetto fisico con quello delle altre persone (Phillips, 2009; Phillips & Diaz, 1997; Phillips et al., 2005; Veale & Riley, 2001). I comportamenti ripetitivi e le azioni mentali che le persone con BDD possono mettere in atto sono potenzialmente illimitati (Phillips, 1998), e includono la ricerca di interventi di chirurgia plastica e medicina estetica che hanno l’obiettivo di eliminare i presunti difetti nell’aspetto fisico (Crerand, Phillips, Menard, & Fay, 2005; Phillips, Grant, Siniscalchi, & Albertini, 2001); queste procedure, tuttavia, non determinano una riduzione della gravità del BDD e della sintomatologia clinica associata (Crerand et al., 2005; Phillips et al., 1993; Phillips et al., 2001). Inoltre, a seguito di interventi di chirurgia plastica e medicina estetica, alcuni pazienti con BDD possono presentare un peggioramento della sintomatologia clinica e sviluppare nuove aree corporee di preoccupazione (Crerand et al., 2005; Phillips et al., 2001; Veale, 2000; Veale et al., 1996). Oltre alle preoccupazioni inerenti l’aspetto fisico, le persone con BDD sono caratterizzate da bassi livelli di autostima, elevato perfezionismo ed elevati tassi di comorbidità (Phillips, 2006; Phillips et al., 1993; Phillips et al., 2005). I disturbi che più frequentemente si associano in comorbidità con il BDD sono il Disturbo Depressivo Maggiore (DDM), il Disturbo d’Ansia Sociale, il Disturbo Ossessivo-Compulsivo (DOC) e l’Anoressia Nervosa (AN; Dingemans, van Rood, de Groot, & van Furth, 2012; Grant, Kim, & Eckert, 2002; Gunstad & Phillips, 2003). Nonostante il crescente interesse nei confronti del BDD negli ultimi anni, questo disturbo continua a essere poco studiato (Buhlmann & Winter, 2011; Buhlmann et al., 2010), soprattutto nel contesto Italiano. Infatti, le ricerche volte a indagare la prevalenza e la fenomenologia del BDD nel contesto Italiano sono limitate, e non esistono attualmente dati di prevalenza secondo i criteri diagnostici del DSM-5 (APA, 2013). Di conseguenza, l’obiettivo principale del presente contributo è quello di indagare la prevalenza del BDD, la sua fenomenologia, le caratteristiche cliniche associate e le popolazioni a rischio attraverso tre studi.
Il primo studio del presente contributo si è posto come obiettivo quello di indagare la prevalenza e le caratteristiche fenomenologiche del BDD, così come le caratteristiche cliniche associate (autostima, perfezionismo, ansia sociale e sintomi depressivi e ossessivo-compulsivi). Seicento quindici individui appartenenti alla popolazione generale hanno completato una batteria di questionari self-report volti a valutare la prevalenza e le caratteristiche fenomenologiche del BDD, così come le caratteristiche cliniche associate sopra descritte. I risultati ottenuti hanno mostrato che 10 (1.63%) partecipanti hanno soddisfatto i criteri diagnostici per il BDD secondo il DSM-5 (APA, 2013). Capelli (n = 4; 4%), naso (n = 4; 4%) e denti (n = 4; 4%) sono risultate le aree del corpo di maggiore preoccupazione tra coloro che hanno soddisfatto i criteri diagnostici per il BDD. In riferimento alle caratteristiche cliniche associate, gli individui che hanno soddisfatto i criteri diagnostici per il BDD hanno riportato minore autostima e maggiore ansia sociale, distress generale e sintomi depressivi e ossessivo-compulsivi rispetto a coloro che non hanno soddisfatto i criteri diagnostici per il BDD. Questi risultati mettono in evidenza che, nel contesto Italiano, il BDD è un disturbo relativamente comune e che si associa a elevata sintomatologia clinica.
Il secondo studio del presente contributo ha preso in considerazione sia il BDD sia l’AN. Sia il BDD sia l’AN, infatti, sono gravi disturbi dell’immagine corporea (Rosen, Reiter, & Orosan, 1995) caratterizzati da insoddisfazione per il corpo, pensieri intrusivi rispetto all’aspetto fisico e da una sovrastima dell’importanza dell’aspetto fisico nella valutazione del valore di sé (Rosen & Ramirez, 1998). Inoltre, sono entrambi caratterizzati da bassa autostima Phillips, Pinto, & Jain, 2004; Rosen & Ramirez, 1998) e da elevati livelli di perfezionismo (Bardone-Cone et al., 2007; Buhlmann, Etcoff, & Wilhelm, 2008; Bulik et al., 2003; Veale, 2004). Numerosi studi hanno sottolineato la presenza di elevata comorbidità tra BDD e AN (Dingemans et al., 2012; Fenwick & Sullivan, 2011; Grant et al., 2002; Kollei, Schieber, Zwaan, Svitak, & Martin, 2013; Ruffolo, Phillips, Menard, Fay, & Weisberg, 2006); inoltre, i pazienti con AN frequentemente riportano la presenza di preoccupazioni non relative al peso e alla forma del corpo (Dingemans et al., 2012; Grant et al., 2002; Kollei et al., 2013). I pazienti con AN e BDD in comorbidità, inoltre, presentano una maggiore insoddisfazione per il corpo e una maggiore sintomatologia clinica rispetto a coloro che non presentano BDD in comorbidità (Dingemans et al., 2012; Grant et al., 2002). Di conseguenza, il primo obiettivo del presente studio è stato quello di indagare la prevalenza del BDD e la presenza di preoccupazioni non inerenti il peso e la forma del corpo in pazienti con AN. In secondo luogo, lo studio si è proposto di confrontare pazienti con AN e preoccupazioni non inerenti il peso e la forma del corpo, pazienti con AN e preoccupazioni inerenti esclusivamente il peso e la forma del corpo e un gruppo di controllo rispetto all’immagine corporea e alle caratteristiche psicologiche e psicopatologiche associate. Per questi scopi, 61 pazienti donne con AN sono state suddivise in due gruppi: 39 pazienti con preoccupazioni non inerenti il peso e la forma del corpo e 22 pazienti con preoccupazioni inerenti esclusivamente il peso e la forma del corpo. Inoltre, un gruppo di controllo composto da 61 donne appartenenti alla popolazione generale è stato reclutato. I risultati principali dello studio hanno mostrato che 16 (26.23%) pazienti con AN presentavano BDD in comorbidità e le più comuni preoccupazioni non inerenti il peso e la forma del corpo sono risultate i capelli (41.02%), il naso (30.77%), la pelle (30.77%), i denti (25.64%), e l’altezza (20.51%). Le pazienti con AN e preoccupazioni non inerenti il peso e la forma del corpo, inoltre, hanno presentato maggiore psicopatologia non inerente i disturbi del comportamento alimentare rispetto alle pazienti con AN e preoccupazioni esclusivamente inerenti il peso e la forma del corpo, in accordo con i risultati emersi in altri studi (Dingemans et al., 2012; Grant et al., 2002). Di conseguenza, le pazienti con AN e preoccupazioni non inerenti il peso e la forma del corpo hanno riportato una maggiore compromissione dell’immagine corporea non correlata a una maggiore gravità del disturbo alimentare.
Infine, il terzo studio del presente contributo mirava a indagare la prevalenza del Disturbo di Dismorfismo Muscolare (Muscle Dysmorphia; MD), le caratteristiche psicologiche associate e i possibili predittori in tre gruppi (N = 125) di atleti Italiani non professionisti. MD è un sottotipo di BDD caratterizzato dalla preoccupazione che il proprio corpo non sia sufficientemente muscoloso (APA, 2013; Pope, Gruber, Choi, Olivardia, & Phillips, 1997); tuttavia, gli individui con MD hanno un corpo normale o sono addirittura molto muscolosi, molto più della media delle persone (Pope et al., 1997). Il primo obiettivo del presente studio è stato quello di indagare la prevalenza e la fenomenologia della MD in 3 gruppi di individui praticanti sport a livello ricreativo: 42 bodybuilders, 61 atleti praticanti sollevamento pesi e 22 atleti che si allenano in palestra. In secondo luogo, sono stati valutati i comportamenti e le caratteristiche psicologiche associate all’MD, tra cui autostima, perfezionismo, ansia sociale, ortoressia nervosa e distress generale tra i 3 gruppi di sportivi. Infine, il presente studio si è posto l’obiettivo di valutare la presenza di associazioni tra MD e le caratteristiche psicologiche associate nei tre gruppi e, con scopo esplorativo, di indagare i possibili predittori della MD tra i tre gruppi. I risultati dello studio hanno mostrato una prevalenza dell’MD del 6.4%: 4 partecipanti (9.52%) nel gruppo dei bodybuilders, 2 partecipanti (3.28%) nel gruppo degli atleti che sollevano pesi e 2 partecipanti (9.09%) nel gruppo di coloro che si allenano in palestra hanno soddisfatto i criteri di Pope e colleghi (1997) per la MD. Rispetto alle cognizioni e ai comportamenti tipici associati alla MD, il gruppo dei bodybuilders ha riportato più frequentemente di pensare di assumere steroidi anabolizzanti (anabolic-androgenic steroids; AAS), di assumere più di 2 gr di proteine al giorno e di avere pensieri relativi al voler essere più muscolosi rispetto agli altri due gruppi di sportivi. Per quanto riguarda la sintomatologia generale tipica della MD, invece, essa è stata riportata in maniera più elevata dal gruppo dei bodybuilders solo rispetto al gruppo che si allena in palestra. Inoltre, il gruppo di sportivi che solleva pesi ha riportato maggiori livelli di perfezionismo rivolto verso il sé rispetto agli altri due gruppi. Infine, diversi pattern correlazionali sono emersi tra i tre gruppi, così come diversi predittori. Nello specifico, la sintomatologia di ansia sociale è risultata predittiva della sintomatologia MD sia per il gruppo dei bodybuilders sia per il gruppo degli atleti che sollevano pesi, mentre non sono emersi predittori significativi nel gruppo di sportivi che si allena in palestra. In conclusione, i risultati del presente studio sottolineano che il perseguimento di un fisico muscoloso negli atleti che praticano bodybuilding non è necessariamente associato alla MD e alle caratteristiche psicologiche a essa associate.
Per concludere, questo contributo fornisce spunti clinici, strategie preventive e implicazioni per il trattamento del BDD nelle popolazioni considerate a rischio.

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EPrint type:Ph.D. thesis
Tutor:Ghisi, Marta
Ph.D. course:Ciclo 29 > Corsi 29 > SCIENZE PSICOLOGICHE
Data di deposito della tesi:30 January 2017
Anno di Pubblicazione:2017
Key Words:Disturbo di Dismorfismo Corporeo (Body Dysmorphic Disorder); Immagine Corporea (Body Image); Caratteristiche Psicologiche (Psychological Features); Caratteristiche Psicopatologiche (Psychopathological Features); Disturbo di Dismorfismo Muscolare (Muscle Dysmorphia).
Settori scientifico-disciplinari MIUR:Area 11 - Scienze storiche, filosofiche, pedagogiche e psicologiche > M-PSI/08 Psicologia clinica
Struttura di riferimento:Dipartimenti > Dipartimento di Psicologia Generale
Codice ID:10170
Depositato il:14 Nov 2017 12:23
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