Doi:10.1016/j.janxdis.2007.05.004

Journal of Anxiety Disorders 22 (2008) 540–547 Facial attractiveness ratings and perfectionism in body dysmorphic disorder and obsessive-compulsive disorder Ulrike Buhlmann, Nancy L. Etcoff, Sabine Wilhelm Massachusetts General Hospital and Harvard Medical School, United States Received 28 February 2007; received in revised form 14 May 2007; accepted 17 May 2007 Individuals with body dysmorphic disorder (BDD) suffer from a preoccupation about imagined or slight appearance flaws. We evaluated facial physical attractiveness ratings and perfectionistic thinking among individuals with BDD (n = 19), individuals withobsessive-compulsive disorder (OCD; n = 21), and mentally healthy control participants (n = 21). We presented participants withphotographs displaying faces varying in facial attractiveness (attractive, average, unattractive) and asked them to rate them in termsof their physical attractiveness. We further examined how the participants evaluated their own physical attractiveness, relative toindependent evaluators (IEs). As predicted, BDD participants perceived their own attractiveness as significantly lower than did theIEs, and they rated photographs from the category ‘‘Attractive’’ as significantly more attractive than did the other groups.
Furthermore, both clinical groups were characterized by more perfectionistic thinking than controls. These findings mostly supportcognitive-behavioral models of BDD that suggest that individuals with BDD exhibit perfectionistic thinking and maladaptiveattractiveness beliefs.
# 2007 Elsevier Ltd. All rights reserved.
Keywords: Body Dysmorphic Disorder; Obsessive-Compulsive Disorder; Physical attractiveness; Facial attractiveness; Perfectionism; Self-discrepancy Body dysmorphic disorder (BDD) is a chronic and hours a day. Avoidance of everyday activities, and debilitating disorder characterized by distress about engagement in ritualistic behaviors, such as mirror checking, grooming, and comparing one’s own appear- ance with other people’s appearance may lead to BDD are often preoccupied with flaws in their skin, hair, nose, ears, or other body parts that are either completely imaginary or, if there is a slight physical defect, their Recent research on maladaptive beliefs and attitudes concern is excessive. These concerns often compel BDD sufferers to think about their appearance for many has led to the development of cognitive-behavioralmodels of the etiology and maintenance of BDD (e.g.,model, * Corresponding author at: Body Dysmorphic Disorder Clinic, for example, proposes that individuals with BDD Simches Research Building, Department of Psychiatry, Massachusetts misinterpret visual input from normal features or minor General Hospital, 185 Cambridge Street, Boston, MA 02114, United appearance flaws, leading to worry, anxiety, shame, and States. Tel.: +1 617 724 6146; fax: +1 617 643 3080.
maladaptive coping rituals, such as mirror checking, 0887-6185/$ – see front matter # 2007 Elsevier Ltd. All rights reserved.
U. Buhlmann et al. / Journal of Anxiety Disorders 22 (2008) 540–547 excessive grooming behaviors, frequent asking for ), supporting the idea that perfectionism is reassurance, or comparing their own appearance with associated with psychopathology. Moreover, it has been others’. According to this model, most people dislike found that individuals with BDD endorse beliefs, such as some aspects of their appearance, but individuals with ‘‘I have to have perfection in my appearance’’ BDD focus on these details, exaggerating their perceived or slight defects in appearance. Moreover, To our knowledge, facial attractiveness ratings and perfectionism have not yet been examined in BDD. In maladaptive beliefs about their attractiveness, such as the current study, we investigated whether BDD higher attractiveness standards and perfectionistic sufferers exhibit higher levels of perfectionism than thinking, which lead to a negative self-evaluation and control participants. Further, we investigated whether low self-esteem. Moreover, higher levels of perfection- BDD participants exhibit idiosyncratic or stricter ism may partly explain why individuals with BDD focus ratings for physical attractiveness than control partici- excessively on, and suffer from, their ‘‘imperfect’’ pants (and in particular whether these standards apply in general or only for themselves). Additionally, we According to the self-discrepancy theory ( investigated whether these phenomena are typical only discrepancies between the actual self and the for BDD or whether they characterize a broader ‘‘self-guides’’ (ideal and ought/should self) are expected spectrum of psychological disorders, such as OCD.
to result in negative emotions. Thus, given that Based on clinical observations that BDD sufferers are individuals with BDD often compare their own often characterized by thoughts, such as ‘‘As long as I don’t look perfect, I won’t be able to be happy,’’ we expected that BDD participants would show levels of thinking and discrepancies between one’s own perceived inflated perfectionistic thinking, as has been shown in attractiveness and the perceived ‘‘ideal looking appear- ance’’ lead to more unfavorable social comparisons with However, because OCD is not characterized by a others. This, in turn, may result in more negative preoccupation with one’s physical appearance, we emotions and low self-esteem. Initial support for this hypothesized that OCD participants, unlike BDD participants, would exhibit attractiveness ratings similar to mentally healthy control participants.
duals with BDD exhibited significant discrepanciesbetween their actual self and their ‘‘ideal’’ and ‘‘should’’ selves. So far, the current models of BDD arepredominately based on clinical observations. While there is some evidence that attention, interpretations ofsituations as well as emotion recognition are biased in The BDD group was comprised of 19 participants (six men) who met current DSM-IV ) criteria for BDD as determined by structured clinical interviews (Structured Clinical Interview for DSM-IV – Outpatient ). The BDD participants had one or more of the following concerns: facial skin (n = 14), hair (n = 5), breasts (n = 1), eyes (n = 1), and shape of nose (n = 1).
if they see themselves as unattractive or as ‘‘not attractive Although the BDD was the primary diagnosis in all cases enough.’’ Furthermore, it has not been evaluated how (based on symptom severity), some BDD participants individuals with BDD evaluate the appearance of others.
had the following co-morbid diagnoses: major depres- These questions relate to the broader concept of sion (n = 7), agoraphobia without panic disorder (n = 1), perfectionism. Higher levels of perfectionism have been and social phobia (n = 1). Thirteen BDD participants found in a series of disorders, such as depression (e.g., were on a stable dose of psychotropic medication at the time of testing: fluoxetine (n = 7), paroxetine (n = 2), fluvoxamine (n = 3), and clomipramine (n = 1).
The OCD group was comprised of 21 participants (10 men) who met current DSM-IV ) criteria U. Buhlmann et al. / Journal of Anxiety Disorders 22 (2008) 540–547 The participants had one or more of the following the surrounding head, neck, and shoulders. The photos symptoms: contamination fears (n = 9), aggressive were taken of 18 females and 18 males who varied in obsessions (n = 5), sexual obsessions (n = 2), fear of physical attractiveness (six attractive, six average, and making mistakes (n = 1), obsessions about guilt (n = 1), six unattractive facial photographs). Facial attractive- religious obsessions (n = 1), rumination (n = 1), check- ness of each stimuli used in the study was carefully ing (n = 15), hand washing (n = 9), counting compul- classified by four independent evaluators (IEs) as sions (n = 2), hoarding (n = 1), and rereading (n = 1).
‘‘unattractive,’’ ‘‘average,’’ or ‘‘attractive.’’ The IEs Although the OCD was the primary diagnosis in all were completely independent and not involved in the cases (based on symptom severity), some OCD study otherwise. Only photographs with an inter-rater participants had the following co-morbid diagnoses: reliability of Kappa ! .97 were included. Moreover, the major depression (n = 2), alcohol abuse (n = 1), panic participants were asked to have their own facial disorder without agoraphobia (n = 1), and chronic photograph taken with a 2.6 megapixel digital camera.
motor tic (n = 1). Nine OCD participants were All facial photographs were presented on high quality unmedicated at the time of testing. The remaining 11 photo paper (6 in. Â 8 in.) in a randomized order.
participants were on a stable dose of the followingpsychotropic medications: fluoxetine (n = 4), parox- etine (n = 3), sertraline (n = 3), and fluvoxamine(n = 1). Data on medication status were missing for All participants completed the Beck Depression The mentally healthy control group consisted of 21 group completed the Body Dysmorphic Disorder participants (nine men). SCID interviews confirmed the Modification of the Yale-Brown Obsessive-Compulsive absence of any psychiatric history. As evident from , the groups did not differ with respect to age and The Beck Depression Inventory (BDI) is a 21-item education, ps > .83, and gender, x2(2) = 1.1, p = .58.
inventory that measures the severity of depression. Each All of the participants were Caucasian. The patients item has a series of four self-evaluative statements that groups were recruited at the OCD Clinic at the indicate the severity of a particular symptom. The total Massachusetts General Hospital (MGH). Control participants were recruited through flyers posted in The Body Dysmorphic Disorder Modification of the the Boston community. All participants were native YBOCS (BDD-YBOCS) is a widely used 12-item clinician-administered modified version of the Yale-Brown Obsessive-Compulsive Scale ). It measures the severity of BDD symptomsduring the past week. The total score ranges from 0 to The Frost Multidimensional Perfectionism Scale is a The experimental material consisted of 36 black and commonly used 35-item self-report measure developed white head-shot photographs of individuals with neutral facial expressions. All photographs used in this study displayed Caucasian faces. Photographs were standar- subscales that assess the following dimensions: (1) dized by isolating the face in an ellipse and graying out concern over mistakes (e.g., people will think less of me Table 1Means of psychometric and questionnaire data Notes. BDD-YBOCS: Body Dysmorphic Disorder Modification of the Yale-Brown Obsessive-Compulsive Disorder Scale; BDI: Beck DepressionInventory; BDI data of one OCD participant were missing; means sharing letters do not differ ( ps > .05, as determined by ANOVAs and follow upBonferroni-corrected t-tests).
U. Buhlmann et al. / Journal of Anxiety Disorders 22 (2008) 540–547 if I make a mistake), (2) doubts over actions (e.g., even attractiveness on a Likert-scale from 1 (very unat- if I do things carefully, I often feel that it is not quite tractive) to 7 (very attractive). The experimenter done right), (3) personal standards (e.g., I set higher emphasized that they ought to rate the photographs goals for myself than most people), (4) parental (including their own) in terms of how attractive they expectations (e.g., my parents wanted me to be best personally think the individuals displayed on the at everything), (5) parental criticism (e.g., as a child, I photographs are and not what other people might think.
was punished for doing things less than perfectly), and Of note, the experimenter left the room after the (6) organization (e.g., I try to be a neat person). The last instructions had been fully explained, and the subscale (organization) was not included in the total participants then completed the tasks. Afterwards, score. The total score ranges from 0 to 140. All the participants completed the BDI and FMPS and were measures used in this study have good psychometric asked if they would agree to have their photograph rated by IEs in terms of their physical attractiveness.
Finally, they were paid and debriefed about the purpose The study protocol was approved by the Partners Human Research Committee, which oversees researchat MGH. Written informed consent of the participants was obtained after the nature of the procedures hadbeen fully explained. All participants were tested One-way analyses of variance (ANOVAs) indicated individually. The study consisted of two appointments.
a group difference in the FMPS total score, F(2, At the first appointment, participants read and signed 58) = 5.12, p = .009. Bonferroni-corrected t-tests indi- the informed consent form prior to receiving a SCID cated that control participants had lower overall interview. The experimenter (U.B.) also administered perfectionism scores than BDD participants, p = .04, the BDD-YBOCS with the BDD participants at the first and OCD participants, p = .01, whereas both patient appointment. Participants were told that the purpose of groups did not differ in their level of perfectionism, the study was to increase knowledge about individual preferences. After that, the participants’ facial photo- We also found significant group differences for the graphs were taken. At the second appointment (2 days FMPS subscales ‘‘Concern over Mistakes,’’ F (2, later), before the experimental trials, a short practice 58) = 9.98, p < .001, and ‘‘Doubting of Actions,’’ session was given that consisted of presenting the F (5, 58) = 21.54, p < .001. Both patient groups had participants with six additional facial photographs (two significantly more concerns over mistakes than of each category). Participants in the BDD group controls, ps = .001, but no difference was observed received the photographs in different random orders, between the patient groups, p > .99. Interestingly, and participants in the OCD and control group were scores on the FMPS subscale ‘‘Doubting of Actions’’ yoked to the BDD participants. Furthermore, they were showed several significant results. OCD participants asked to rate each photograph in terms of its physical had significantly higher scores than BDD participants, Table 2Means of the Frost Multidimensional Perfectionism Scale Notes. BDD: body dysmorphic disorder; OCD: obsessive-compulsive disorder; Control: Mentally healthy controls; FMPS: Frost MultidimensionalPerfectionism Scale; means sharing letters do not differ ( ps > .05, as determined by ANOVAs and follow up Bonferroni-corrected t-tests).
U. Buhlmann et al. / Journal of Anxiety Disorders 22 (2008) 540–547 p = .01, and control participants, p < .001, and BDD 3.3. Perception of one’s own facial attractiveness participants had significantly higher scores thancontrol To investigate whether the groups differed in their differences were found for the other subscales (see ratings of their own facial attractiveness, we submitted the data for a one-way ANOVA and found a significantdifference among the groups, F(2, 56) = 3.91, p = .03.
Bonferroni-corrected t-tests indicated that BDD parti-cipants rated their own facial photograph as less 3.2.1. Idiosyncratic ratings of attractiveness attractive than did controls, p = .048, or OCD partici- To analyze whether the BDD participants had more pants, p = .048. No difference was obtained between idiosyncratic ratings of beauty, we calculated Spear- OCD participants and controls, p > .99.
man’s Rho rank order correlation (excluding the ratingsof the participants’ own facial photographs). We found 3.4. Relation between one’s own rating and the significant rank order correlations among all groups.
Spearman’s Rhos > .75, ps < .001, indicating that thegroups did not differ in terms of their rank order of To further investigate how the participants rated their own attractiveness compared to the other facialphotographs, we computed paired t-tests, separately for each group. In the BDD group, we found that the Four BDD participants refused to have their photo participants rated their own facial photographs as taken, and their attractiveness ratings were given only slightly less attractive than photographs from the for the other photographs. Facial attractiveness scores category ‘‘Average.’’ This difference, however, fell were submitted to a two-factor (Groups by Facial short of significance, t(14) = À1.87, p = .08. Addition- Attractiveness Category) ANOVA with repeated mea- ally, BDD participants rated their own photograph as sures on Facial Category (Average, Attractive, Unat- significantly less attractive than they rated photographs tractive). As expected, the analysis yielded a significant main effect for Facial Category, F(2, 116) = 635.70, p < .001, and significantly more attractive than they p < .001, and a significant Groups by Facial Category rated photographs from the category ‘‘Unattractive,’’ interaction, F(4, 116) = 3.82, p = .006. The main effect for Groups, however, was not significant, F(2, OCD participants rated their own photographs slightly more attractive than they rated photographs As evident from , Bonferroni-corrected t-tests from the category ‘‘Average,’’ t(20) = 1.77, p = .09, indicated that BDD participants rated photographs from although this difference was not statistically significant.
the category ‘‘Attractive’’ as significantly more attrac- Like the BDD group, they rated their own photographs tive than did controls, p = .001, and OCD participants, as significantly less attractive than they rated photo- p = .02. As expected, there was no difference between graphs from the category ‘‘Attractive,’’ t(20) = À3.80, OCD participants and controls, p = .88. No significant p = .001, and significantly more attractive than they group differences were obtained for any other facial rated photographs from the category ‘‘Unattractive,’’ Table 3Mean ratings of the physical attractiveness categories Notes. Own photograph: rating of the participant’s own photograph by him/herself (BDD group: n = 15); IE ratings: rating of the participant’s ownphotograph by the independent evaluators (BDD group: n = 13, OCD group: n = 16, Controls: n = 19, p-value determined through Wilcoxon tests);means sharing letters do not differ ( ps > .05; as determined by ANOVAs and follow up Bonferroni-corrected t-tests).
U. Buhlmann et al. / Journal of Anxiety Disorders 22 (2008) 540–547 Control participants rated their own photographs as ized by stricter ratings for physical attractiveness for equally attractive to the photographs they rated from the themselves. That is, they rated the attractiveness of their category ‘‘Average,’’ t(20) = 0.97, p = .34. Moreover, own faces as significantly lower than did controls or like the other groups, they rated their own photographs OCD participants, although all groups perceived as significantly less attractive than they rated photo- themselves to be in the average range. All groups rated graphs from the category ‘‘Attractive,’’ t(20) = À3.83, their own attractiveness as significantly lower than they p < .002, and significantly more attractive than they rated photographs from the category ‘‘Attractive’’ and rated photographs from the category ‘‘Unattractive,’’ rated their own attractiveness as significantly higher than they rated photographs from the category‘‘Unattractive.’’ The difference between BDD partici- 3.5. Physical attractiveness ratings of participants’ pants’ ratings of their own facial attractiveness and the ratings for the category ‘‘Average’’ fell short ofsignificance, indicating that BDD participants rated Four IEs who were blind to the group assignation their own facial attractiveness somewhat, but not examined the physical attractiveness of those partici- statistically, lower, than they rated photographs from pants who agreed to have their photograph evaluated the category ‘‘Average.’’ This is somewhat surprising (BDD: n = 13; OCD: n = 16; Controls: n = 19). Overall, given that BDD patients often describe themselves as we found no differences for the physical attractiveness ‘‘ugly’’ in clinical settings. Given that BDD is ratings for any group, F(2, 47) = .03, p = .98. This associated with higher levels of perfectionism, it is indicates that the participants’ level of physical possible that individuals with BDD perceive the label attractiveness, as rated by the IEs, was the same among ‘‘Average’’ as more undesirable and negative than do the groups. We further computed Wilcoxon compar- individuals without BDD. Most importantly, BDD isons to investigate how the participants’ ratings participants perceived their physical attractiveness as less attractive than the IEs (a pattern which was not Within the BDD group, the IEs rated the partici- observed in the OCD and control groups), which pants’ photographs significantly more attractive than supports the clinical assumption that other people do not did the BDD participants, Z = 2.01, p = .04. Within the share the BDD sufferers’ evaluation of perceived OCD group, the IEs rated the participants’ photographs appearance flaws. Thus, it would be interesting to equally attractive as the participants themselves, further examine whether individuals with BDD value Z = 1.14, p = .26. Within the control group, similar to aesthetics and beauty more than individuals without the OCD group, no difference was obtained between the BDD, which may lead them to be more sensitive and IEs’ ratings and the participants’ ratings, Z = 1.42, responsive to attractiveness, which, in turn, may lead them to rate attractive people as even more attractive,more desirable, and closer to ‘‘perfection’’ than other Moreover, our findings are consistent with The aim of the present study was to examine facial self-discrepancy theory. Specifically, perfectio- attractiveness ratings and perfectionistic thinking in nistic thinking and discrepancies between the percep- order to evaluate cognitive-behavioral models of BDD.
tion of one’s own appearance versus how other people’s Results indicate that individuals with BDD did not have attractiveness is perceived may lead to more unfavor- more idiosyncratic ratings of beauty, compared to able social comparisons with others and consequently to individuals with OCD and healthy control participants.
negative emotions and low self-esteem (e.g., the beauty That is, they did not rate the facial photographs of people varying in physical attractiveness any different In support of our hypothesis, we also found that BDD than did the other groups. However, BDD participants participants as well as OCD participants showed higher rated attractive faces as more attractive than the other overall levels of perfectionism than did controls. In groups. Further, individuals with BDD were character- particular, both clinical groups exhibited more concernsover mistakes than controls. The ‘‘Concern overMistakes’’ subscale reflects negative reactions to imperfections, a tendency to interpret imperfections To examine whether co-morbid depression had influenced our as equivalent to failure, and a tendency to believe that results, we re-ran the analyses, including the BDI as a covariate. Thepattern of results did not change.
one will lose the respect of others as a result of U. Buhlmann et al. / Journal of Anxiety Disorders 22 (2008) 540–547 imperfection. Thus, future research needs to explore everyone agreed to have their photograph evaluated by whether concerns about imperfections (perhaps in the the IEs. Thus, those results have to be interpreted with form of minor appearance flaws or a perceived some cautions and larger scale studies are needed to appearance defect) and self-worth have become replicate and further investigate this matter. For example, interwoven. This could explain why individuals with it is possible that those participants who did not agree to BDD are very concerned when they perceive their hair have their picture taken or rated by the IEs were more as thinning or their skin as scarred.
severely impaired, which may have affected our results.
In addition, OCD participants had the highest levels In addition, given that our results rely on self-report of doubting of action, followed by BDD participants, measures, it would be interesting to examine the who, in turn, had higher levels of doubting than underlying cognitions when rating physical attractive- controls. This result is also consistent with the clinical ness. For example, it is possible that individuals with picture of both disorders, which are characterized by the BDD, relative to individuals without BDD, might prove assumption that certain actions need to be done very more forgiving when confronted with others who have carefully, and need to be repeated over and over. In appearance flaws, or who are less attractive. At the same BDD these actions are usually done with the intention to time they might be very impressed by attractive faces check on, hide or improve appearance, whereas OCD is manifesting in cognitions, such as ‘‘I wish I would look as characterized by other compulsions. To our knowledge, pretty as she does,’’ more so than individuals without this is the first study investigating perfectionism in BDD BDD, which might, in turn, influence their perception of relative to individuals without BDD, and the findings are consistent with our clinical experience that when Overall, the findings are mainly supportive of individuals with BDD think that they do not look ‘‘just cognitive-behavioral models of BDD, which suggest perfect’’ they are dissatisfied with their appearance.
that individuals with BDD are characterized by This study has some limitations. Although the perfectionistic thinking and maladaptive beliefs about majority of our BDD participants (n = 16, based on 14 participants with facial skin concerns, one participant ). Future research needs to address how percep- with nose concerns, and one participant with concerns tions of one’s own and other people’s attractiveness can related to the eyes) endorsed concerns related to their be changed through cognitive-behavioral therapy. For face, three participants did not endorse these concerns.
example, it is possible that over the course of the Thus, it is possible that the results would have been treatment, techniques, such as challenging the utility of slightly different if we had only included BDD perfectionistic thinking, perceptual (mirror) retraining, participants with facial concerns. Furthermore, due to and decreasing rituals, such as comparing influence the the highly sensitive nature of a facial perception study for BDD sufferer’s perception of his or her own and other individuals with BDD, it was impossible to obtain facial photographs of all BDD participants. Furthermore, alarge number of individuals in the clinical groups were on a stable dose of psychotropic medication at the time of thetesting and future research needs to explore the possible This research was supported, in part, by a graduate impact of medication on attractiveness ratings. Also, fellowship of the Gottlieb Daimler – and Karl Benz- although our results did not change after controlling for Foundation, Germany, awarded to Ulrike Buhlmann.
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