The Relative Associations of Body Image Dissatisfaction among Psychiatric Out-Patients in Singapore

Round 1

Reviewer 1 Report

The authors conducted an intensive research about hidden body dissatisfaction in psychiatric outpatients. This manuscript seems to have plentiful results.

However, some minor points below should be improved or explained.

 

#1 Why ICD-9R, not ICD-10 or 11 was used as criteria (line 79)? The authors should explain the reason, and the years when the data was collected should be shown.

#2 The number of total approaches for possible participants should be shown. Please let us know the denominator of 310 recruitments.

#3 High EAT-26 scores do not always mean having eating disorder diagnosis (i.e. Hayakawa et al., BMC Research Notes 2019). The expression in lines 208 to 210 should be attenuated.

#4 Only schizophrenia spectrum disorders and depressive disorders were included in this study. The authors should state the reason why patients diagnosed as eating disorders were excluded in the Discussion section.

#5 The appearance of the manuscript should be fixed in some parts. An irregular font size (lines 44 to 47) and irregular spacing around equal signs (lines 163 to 176) are seen. 

Author Response

Respected reviewers,

Thank you and appreciate your help in the form of comments/suggestions in order to make the manuscript better.

Why ICD-9R, not ICD-10 or 11 was used as criteria (line 79)? The authors should explain the reason, and the years when the data was collected should be shown.

We have used ICD-9R criteria for classification as our institute’s clinical data management system follows it for disease classification.

The number of total approaches for possible participants should be shown. Please let us know the denominator of 310 recruitments.

For our research studies we do not collect the information on number total approaches for possible participants as all the participants  we recruit  are outpatients and we screen them as per our eligibility criteria for the respective study.

Only schizophrenia spectrum disorders and depressive disorders were included in this study. The authors should state the reason why patients diagnosed as eating disorders were excluded in the Discussion section.

Only schizophrenia spectrum disorders and depressive disorders were included in this study as the proposed research question was to study the prevalence, potential consequences and correlates of BID among these two patient groups.

The appearance of the manuscript should be fixed in some parts. An irregular font size (lines 44 to 47) and irregular spacing around equal signs (lines 163 to 176) are seen. 

Above mentioned changes are made in the manuscript.

Reviewer 2 Report

This paper presents an analysis of survey data regarding the relationship between body image dissatisfaction (BID) and a range of demographic and psychological factors in a sample of young and middle adults receiving outpatient treatment for psychiatric disorders in Singapore. Strengths of this study include the inclusion of a vulnerable and under-represented population, and the use of a strong set of measures for the key constructs. There are some issues regarding the analysis and some elements of the discussion that I think could be improved.

The rationale for model 2 is not explained clearly. The background and discussion both frame the psychological and behavioral measures (anxiety, depression, binge eating risk, eating attitude risk) as consequences of BID, but the analysis is structured with BID (assessed with BSQ) as the outcome and these psychological/behavioral factors as predictors. The result is that the implications of the results of the second regression model are not straightforward – we see the results in terms of the relationship of the predictors with BSQ after controlling for other predictors, but it is not clear why this is a useful way of framing the data. It would make more sense based on the introduction to look at the bivariate relationship between BSQ and the psychological/behavior outcomes, and perhaps also at a model in which the behavioral risk outcomes (binge eating and eating attitude risk) were treated as outcomes. Then you could examine the results in terms of the relationship between BID and negative outcomes after controlling for anxiety and depression. Of course, none of these potential ways of structuring the analysis would allow for causal inference, but it would build a more logical case with clearer clinical implications. Alternatively, a stronger case needs to be made within the text to justify the current analytical approach. I do not see descriptive statistics presented anywhere for the psychological/behavioral variables (anxiety, depression, binge eating risk, eating attitude risk). These should be added either in the text or in Table 1. The concluding paragraph very briefly addresses some clinical implications of the study – that it would be useful to include BID screening when treating this population – but this is important enough to be developed somewhat more. A short paragraph about how the findings might be important for informing clinicians about the needs of this population would be a helpful addition. It is mentioned near the end of the discussion that a substantial majority of the population of Singapore is literate in English. This would be useful information to note much earlier in the paper, where the sample is described, to help support and contextualize the use of English survey instruments. The statement in the first paragraph of the discussion section is confusing, because it states that the rate of BID in this study is lower, at 14.8% - 30.9%, than seen in another study at 22.1%, whereas 30.9 is greater than 22.1. Presumably the definition of BID used in that study was closer to the group of 14.8% in this study than with the 30.9%, but this would be clearer with more explanation. There is at least one instance in which “BDI” is used where it looks like “BID” was intended (line 262). Since the BDI was also administered in this study, the two are easy to confuse.

Author Response

Respected reviewers,

Thank you and appreciate your help in the form of comments/suggestions in order to make the manuscript better.

 

The background and discussion both frame the psychological and behavioral measures (anxiety, depression, binge eating risk, eating attitude risk) as consequences of BID, but the analysis is structured with BID (assessed with BSQ) as the outcome and these psychological/behavioral factors as predictors. The result is that the implications of the results of the second regression model are not straightforward – we see the results in terms of the relationship of the predictors with BSQ after controlling for other predictors, but it is not clear why this is a useful way of framing the data. It would make more sense based on the introduction to look at the bivariate relationship between BSQ and the psychological/behavior outcomes, and perhaps also at a model in which the behavioral risk outcomes (binge eating and eating attitude risk) were treated as outcomes. Then you could examine the results in terms of the relationship between BID and negative outcomes after controlling for anxiety and depression. Of course, none of these potential ways of structuring the analysis would allow for causal inference, but it would build a more logical case with clearer clinical implications. Alternatively, a stronger case needs to be made within the text to justify the current analytical approach. I do not see descriptive statistics presented anywhere for the psychological/behavioral variables (anxiety, depression, binge eating risk, eating attitude risk). These should be added either in the text or in Table 1.

Tables with relevant information included in the manuscript

The concluding paragraph very briefly addresses some clinical implications of the study – that it would be useful to include BID screening when treating this population – but this is important enough to be developed somewhat more. A short paragraph about how the findings might be important for informing clinicians about the needs of this population would be a helpful addition.

Relevant information added to the manuscript.

 

 It is mentioned near the end of the discussion that a substantial majority of the population of Singapore is literate in English. This would be useful information to note much earlier in the paper, where the sample is described, to help support and contextualize the use of English survey instruments.

-Included in the methodology of the manuscript.

 

The statement in the first paragraph of the discussion section is confusing, because it states that the rate of BID in this study is lower, at 14.8% - 30.9%, than seen in another study at 22.1%, whereas 30.9 is greater than 22.1. Presumably the definition of BID used in that study was closer to the group of 14.8% in this study than with the 30.9%, but this would be clearer with more explanation.

Table 1. included in the manuscript that clarifies the above comment.

 

There is at least one instance in which “BDI” is used where it looks like “BID” was intended (line 262). Since the BDI was also administered in this study, the two are easy to confuse. 

Correction made.

 

Author Response File: Author Response.docx

This manuscript is a resubmission of an earlier submission. The following is a list of the peer review reports and author responses from that submission.