Mood disorders (MD) represent a complex and significant group of psychiatric conditions that profoundly impact emotional states. These encompass diagnostic categories such as bipolar and depressive disorders (1). From a cognitive point of view, MDs involve self-oriented negative thoughts characterized by selective attention to internal or external stimuli, repetitive thinking, and biased reasoning processes (2). These cognitive patterns are observed in both unipolar and bipolar disorders (3, 4), making them critical targets for cognitive treatments (2).

From a psychopathological point of view, this negative thinking is related to poor self-esteem, affecting mental and physical health (5), with specific implications for depressive psychopathology (6). Self-esteem and self-perception contribute to depression and body dissatisfaction, suggesting a role for cognitive patterns in the development and maintenance of depression symptoms (5, 7). The link between depression and body evaluation often involves negative perceptions and judgments of one’s body and has been stressed particularly in the context of eating disorders and body dysmorphic disorder (8). However, it seems simplistic to focus only on this population due to the existing knowledge that weight bias (WB) seems to persist as one of the few remaining forms of discrimination that society tolerates (9).

WB encompasses a spectrum of negative attitudes, beliefs, judgments, and stereotypes directed toward individuals based on their body weight, including both explicit and implicit biases. It extends beyond literal weight measurements to incorporate societal perceptions of body shape and size, exerting a profound influence on body evaluation (10, 11). WB may significantly influence the mood spectrum due to internalized self-stigmatization (12) and may manifest in various ways, including overt discrimination, subtle microaggressions, and internalized self-stigmatization, contributing to psychological distress. Explicit biases are conscious and intentional, while implicit biases operate at an unconscious level (13). Evaluating both conscious attitudes and unconscious biases allows us to capture a more comprehensive understanding of individuals’ perspectives and behaviors, providing valuable insights for targeted interventions and contributing to a broader societal shift in perceptions, due to the presence of different cognitive information processing systems (14). WB plays a crucial role in self-evaluation and exhibits intricate relationships with psychopathological expressions such as disordered eating, body dissatisfaction, and body shape overvaluation (15–17). Negative self-evaluation stemming from WB contributes to psychological distress, potentially distorting self-schema, and contributing to conditions such as eating disorders and overweight (10, 18, 19). This bias could also explain the high comorbidity rates between depression, eating disorders, and weight fluctuations (20–22). Psychiatric and medical disorders often correlate with different aspects of body-related judgments, such as weight-related attitudes, internalized thinness ideals, and fear of weight gain (17). Longitudinal studies emphasize the impact of poor body image on psychopathological trajectories, influencing well-being, anxiety, and depression (23–25).

A single study has examined the connection between depressive symptoms and body size misperception, revealing that greater clinical symptoms correlate with increased perceptual body image and increased body dissatisfaction (26), prompting further discussion. Internalization of WB predicts poorer mental and physical health, with positive body feelings that counteract internalized weight stigma and encourage healthy behaviors (27, 28). However, existing studies often focus on nonclinical populations (29), and the relationship between depression and WB remains debatable, with evidence supporting bidirectional influences (30–32). Recent reviews confirm a robust association between depression severity and body weight dissatisfaction, even in limited studies of mood spectrum disorder (26). However, the high weight prevalence in most participants limits generalizability (33), highlighting the need for more research on WB, especially among clinically depressed individuals. For these reasons, we decided to apply the methods used in the field of weight and eating disorders to individuals with mood disorders. Indeed, several aspects have been identified as shared pathophysiological mechanisms that may involve eating dysregulation, mood dysregulation, impulsivity, and compulsivity (34). This calls for further studies to enhance our understanding of the clinical overlap between these two conditions (35).

The BodyTalk Project endeavors to comprehensively evaluate implicit and explicit body image perceptions within diverse populations afflicted by eating and weight disorders (18, 19), employing a semantic methodology to unravel the linguistic portrayal of bodies within clinical settings. A pivotal component of this project involves the utilization of realistic, metrically accurate 3D human avatars, serving as a visual representation of body stereotypes by correlating perceived 3D body shapes with linguistic descriptions of body shapes (36, 37). This approach facilitated a deeper understanding of how language influences perceptions of body image, offering valuable insights into the intricate interplay between language and body representation in clinical contexts.

Addressing the similarities in cognitive vulnerabilities between major depression and bipolar disorder (4) and their potential links with negative self-judgment (38), our study aims to expand the knowledge of weight-related dysfunctional cognitive biases in MD patients, potentially informing interventions. This exploratory pilot analysis examines the representation of mental body image in MD patients, with a focus on implicit and explicit weight biases. Our primary hypothesis posits a self-related WB due to underlying cognitive self-judgments in people with MD compared to the general population. Additionally, our objective is to specifically investigate body image disturbance, a less explored aspect in MDs.

The primary objective of this study was to fully assess WB concerns among MD patients and to identify specific differentiators compared to their healthy counterparts. Understanding these distinctions could provide insight into the cognitive self-negative assessment that characterizes this population. Our findings support the core hypothesis, revealing that negative WB could be a component of the maladaptive cognitive patterns associated with depression.

When examining WB, our results revealed significant disparities in weight-based ratings between MD participants and healthy controls, particularly within the average BMI range. The patterns observed in our CP group are consistent with previous literature, showing an inverted U-shape trend in which individuals rated average-range weights (18.5 < BMI < 25.0 kg/m2) more favorably than underweight or overweight figures (49). On the contrary, our MD patients exhibited a distinct distribution in the evaluation of body shapes. Graphical representations indicated an implicit WB in both groups toward overweight and obese bodies, with no noticeable differences between them. However, MD patients did not manifest a more positive assessment of healthy weights (within the range of 18.5 to 25 kg/m2), as was evident in CP judgments. This absence of a favorable evaluation for healthy weights may help explain the higher Drive for Thinness scores and the greater overestimation of body weight reported by MD patients. The lack of a positive evaluation for healthy weights and shapes suggests a cognitive-affective distortion, indicating that these cognitive patterns may not be as all-encompassing and structured as those observed in eating disorders (18). However, they could still exert a detrimental impact on mood. Consequently, MD patients appear to view all aspects of themselves as inadequate, including their healthy weight. It should be noted that prior research has demonstrated an independent relationship between depressive symptoms and body weight dissatisfaction, regardless of BMI (50). Furthermore, studies have reported an association between uncorrected self-reported BMI and depression (51). In this context, implicit WB could play a role in psychopathology and requires further exploration.

Furthermore, our findings suggest a potential implicit cognitive disparity in the attraction of MD patients to thin-ideal bodies versus their aversion to non-thin bodies, which could contribute to internalized WB (15). Although no discernible differences in explicit WB emerged, it is possible that the structure of the FPS could limit disparities between implicit and explicit bias. However, the notion that negative self-evaluation may be more influenced by implicit assessments implies that future interventions should prioritize personalized implicit bias, particularly in the context of positive body image (52).

Finally, we observed no specific distinctions in body image concerns between MD patients and controls. This was a secondary aim in our study due to the limited evidence present in the literature. These findings align with the prevalent evidence that highlights the conceptual nature of body dissatisfaction in MD, which differs from the more perceptual distortion associated with eating disorders (53, 54). Our sample predominantly comprises young adults with relatively short disease duration, potentially contributing to a more accurate body evaluation (55). In particular, explicit body dissatisfaction was absent, a facet that has not been extensively evaluated in previous studies (26). Overall, our findings underscore the need for more research investigating body perception and depression between different age groups, as this area remains underrepresented in the current literature. It is also possible that the instruments applied might not be suitable for patients with MD due to their specific focus on eating disorders (56). This aspect should be evaluated in future research.

Furthermore, our results emphasized that drive to thinness is the predominant body-related concern among MD patients. This preoccupation may be related to an overestimation of body shape, as indicated by our findings. The DT construct could also be associated with the internalization of positive judgments surrounding low body weight, consistent with literature demonstrating such trends concerning average body representation (57). While DT is the primary concern associated with body shapes in the non-eating-disorder population, potentially reflecting the internalization of Western cultural ideals of thinness (15), it is noteworthy that DT also serves as a dysfunctional coping strategy for low self-esteem and depressive symptomatology (58, 59). From this point of view, our findings align with the body of evidence indicating that self-esteem, DT, and depression are interrelated constructs that significantly impact individuals’ psychological well-being, even among those without eating psychopathology or extreme weight conditions (i.e., extreme underweight or overweight) (60).

Several limitations intrinsic to our study’s experimental design warrant consideration. The most relevant limit of this study is the sample size of the groups included which limits the generalizability of the results. Given the exploratory nature of this study, our results should be validated with a larger sample size that includes a more diverse representation of genders (45). In addition, the assessment of psychological concerns surrounding the body was based on self-report scales. Future studies could employ various methodologies to evaluate both implicit and explicit WB within the MD population, potentially adopting a longitudinal approach to unravel the temporal and causal relationships between WB and depression. For example, implicit association tasks could be applied in this specific population to corroborate our results regarding the potential influence of judgments across different weight categories. Additionally, future body perception may need to encompass other cultural variables (e.g. sexual orientation) that could exert influence on clinical presentation (61). Lastly, the potential impact of depression deserves careful consideration. The existing literature on eating disorders has underscored the role of depression in WB and body shape assessment (62), which potentially signals a more pronounced influence among MD patients, which merits exploration through longitudinal investigations. Furthermore, future studies investigating potential distinctions between bipolar disorder and major depression could aid in stratifying these variances and identifying potential clinical applications for treatment.

Despite inherent limitations, this study contributes to our understanding of self-evaluation patterns among individuals who are battling depressive symptoms. Our findings suggest the presence of implicit WB and an intriguing potential imbalance within the evaluation system. An aspect that our data contributes to the existing literature is the exploration of the connection between WB and depression in individuals with healthy weight ranges—an area that has received limited attention within the WB literature. The absence of a positive evaluation of body weight could potentially affect the implicit self-schema that individuals apply in their daily lives, thereby influencing the development or perpetuation of depressive symptoms. Furthermore, our findings underscore the multifaceted origin and widespread consequences of negative self-esteem schemes within the MD population. These findings suggest that targeted interventions aimed at addressing both self-evaluation and self-comparison processes could contribute to improving psychological and physical well-being.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

The studies involving humans were approved by Padova Ethics Committees for Clinical Practice. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.

PM: Writing – original draft, Visualization, Software, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. SB: Writing – original draft, Visualization, Validation, Supervision, Methodology, Formal analysis, Conceptualization. CP: Writing – review & editing, Investigation. TT: Writing – review & editing, Investigation. MQ-B: Validation, Supervision, Software, Writing – review & editing, Methodology, Conceptualization. MB: Validation, Supervision, Writing – review & editing, Project administration, Methodology, Conceptualization. KG: Writing – review & editing, Validation, Supervision, Conceptualization. ET: Writing – review & editing, Supervision, Methodology, Conceptualization. AF: Writing – review & editing, Supervision, Project administration, Methodology.