A comprehensive investigation of social cognition in body dysmorphic disorder

Objective Impaired social cognition may contribute to the development and maintenance of body dysmorphic disorder (BDD), yet evidence is often inconsistent or limited to a single task or domain. This study aimed to characterise the social-cognitive profile of individuals with BDD across multiple domains (theory of mind (ToM), emotion recognition, pragmatic inference and empathy). Methods Participants were 61 individuals with BDD and 61 healthy controls. Social cognition was assessed using six tasks: the Hinting Task (inferential ToM), the Awareness of Social Inference Test–Short (TASIT-S; ToM), Reading the Mind in the Eyes Test (ToM), Bell–Lysaker Emotion Recognition Task, TASIT-S Part 1 and Penn Emotion Recognition Test (dynamic and static emotion recognition), TASIT-S ‘say’ (pragmatic inference) and the Questionnaire of Cognitive and Affective Empathy (empathy). Results The BDD group showed selective differences rather than global impairment. Group differences included: participants with BDD demonstrated enhanced TASIT-S ToM ( d = 0.48, 95% CI [0.11, 0.85]), heightened (static) anger recognition ( d = 0.67, 95% CI [0.29, 1.06]), superior pragmatic inference ( d = 0.61, 95% CI [0.24, 0.98]) and elevated cognitive empathy ( d = 0.49, 95% CI [0.09, 0.89]), driven by perspective taking, while Hinting was lower ( d = −0.42, 95% CI [−0.78, −0.06]). No effects were associated with clinical variables. Conclusions Social cognition in BDD is not broadly impaired, instead showing a pattern of heightened sensitivity to threat cues and difficulties with higher-order inferential reasoning. If replicated, these findings may inform cognitive-behavioural approaches by identifying automatic threat responses and inferential social reasoning as potential therapeutic targets.