Application of a transdiagnostic treatment for emotional disorders to body dysmorphic disorder: A randomized controlled trial

Emotion Regulation in Pediatric Obsessive-Compulsive Disorder and Related Interventions: A Scoping Review

BACKGROUND/OBJECTIVES

Maladaptive emotion regulation (ER) and emotion dysregulation (ED) have long been associated with obsessive-compulsive disorder (OCD) as etiological and maintaining factors. Despite building interest in the field along with ancillary research into "rage OCD" (likely an example of ED), targeting the relationship between OCD and ER/ED has been understudied in pediatric OCD populations. The aim of this review was to elucidate the current state of the literature regarding ER/ED, its relationship to pediatric OCD, and related interventions.

METHODS

A scoping review examined how ER/ED are related to OCD, particularly in pediatric populations, and the efficacy of interventions to affect ER/ED for youth, with a focus on youth diagnosed with OCD.

RESULTS

A total of 182 publications were reviewed. While not always consistent, a majority of studies found a significant relationship between measures of ER or ED and OCD broadly, as well as with specific OCD symptom dimensions. A number of previously existing interventions, adaptations of those interventions, and newly presented interventions were found to affect ER/ED in youth; however, few studies have effectively targeted ER/ED for pediatric OCD, specifically. As such, the mechanism of change is not well understood.

CONCLUSIONS

Findings from this review suggest that the increasing focus on ER/ED in pediatric OCD is warranted and in need of continued research. ER/ED can be effectively changed by interventions in youth, but the role ER/ED-change plays in pediatric OCD symptom improvement remains unclear. Implications for future study are examined.

Body dysmorphic disorder

Body dysmorphic disorder (BDD) is an obsessive-compulsive disorder-related psychiatric condition characterized by an intense preoccupation with perceived physical flaws that are not observable by others. BDD affects ~2% of the adult population but is underdiagnosed, partly owing to limited clinician awareness, and undertreated, partly due to limited access to treatment. Research on the aetiology of BDD is scarce but likely involves an interplay between genetic and environmental factors. A few studies suggest functional and structural brain differences (compared with controls) in the regions involved in visual and emotional processing, although firm conclusions about the pathophysiology of the disorder cannot be made at this stage. Diagnosis requires the presence of repetitive behaviours or mental acts typically aimed at checking, correcting or concealing perceived flaws. The disorder typically has its onset before 18 years of age, with a female preponderance in youth but no major gender disparity in adults. Quality of life is markedly impaired across multiple domains and suicide risk is considerable. Evidence-based treatments include cognitive behavioural therapy and selective serotonin reuptake inhibitors. Future research should focus on understanding the biological and environmental factors that increase the risk of BDD, and on improving access to effective treatments, thereby addressing a critical gap in care for this often misunderstood and overlooked disorder.

Advancing Psychosocial Treatment for Body Dysmorphic Disorder: A State-of-the-Science Review

Body dysmorphic disorder (BDD) is an underrecognized, challenging illness with severe comorbidities, demanding urgent advancements in treatment strategies. This state-of-the-science review describes current research on existing BDD treatments, beginning with a detailed discussion of cognitive-behavioral therapy (CBT), the primary psychosocial intervention for BDD, and its foundational theories. We emphasize the significant progress in the field, including the efficacy of face-to-face CBT, the promising outcomes of digital interventions for broadening access to care, and emerging treatments that warrant further exploration. The review also addresses the critical gap of targeted interventions for youth, considering the diseases' typical onset during adolescence. Our review also sheds light on the significant gap in research dedicated to testing these treatments in underserved communities, stressing the importance of including these populations in research and culturally informed and adapted, if necessary, care. The review concludes with recommendations for future directions, outlining areas for ongoing treatment development and research to expand the scope and efficacy of interventions for BDD.

Is cognitive behavioral therapy an efficacious treatment for psychological interventions in body dysmorphic disorders? A meta-analysis based on current evidence from randomized controlled trials

BACKGROUND

Clinical guidelines and some studies recommend cognitive-behavioral therapy (CBT) as the most effective treatment for body dysmorphic disorder (BDD). However, owing to the lack of randomized controlled trials (RCTs), the research evidence is insufficient. This study aimed to explore the effectiveness of CBT in the treatment of BDD using RCTs. This meta-analysis was registered in PROSPERO (CRD42023410577).

METHODS

After a literature search and screening, 11 RCTs with 667 patients were included. The ROB 2.0 tool, funnel plots, sensitivity analysis, and meta-regression analysis were used to assess the quality, publication bias, and sources of heterogeneity.

RESULTS

After CBT intervention, the severity of BDD (SMD = -1.73, 95 % CI (confidence interval) = [-2.90; -0.57]), depression symptoms (SMD = -1.72, 95 % CI = [-3.16; -0.28]), and anxiety levels were all reduced in the patients of the experimental group; the remission of BDD (OR = 7.37, 95 % CI = [2.17; 24.98]) and the response of BDD (OR = 8.86, 95 % CI = [4.85; 16.18]) were all increased; incorrect beliefs such as disability and BABS were also reduced; the quality of life was improved. The difference between the groups was statistically significant (p < 0.01). Meta-regression analysis showed that age and sample size were the predictive factors of the effectiveness of CBT.

LIMITATIONS

The heterogeneity of most meta-analyses was high (I2 > 75 %).

CONCLUSIONS

Although CBT is effective in treating BDD, there is insufficient evidence to suggest that it is the best psychological intervention for BDD. More high-quality evidence is still needed in the future.

Enhancing self-esteem in adults with body dysmorphic symptoms: experimental testing and initial evaluation of a brief internet-based training

BACKGROUND

Low self-esteem is an important factor associated with body dysmorphic concerns. In treatment, self-esteem cannot always be adequately addressed. Internet-based interventions offer a low-threshold and cost-efficient possibility for treating body dysmorphic disorder (BDD).

AIMS

For this reason, we conducted two studies to explore the effectiveness of an internet-based intervention targeting improving self-esteem in adults with BDD symptoms.

METHOD

The first study investigated the differential effects of a 1-week self-esteem training compared with a 1-week attention-focus training. Two hundred twenty adults with elevated body dysmorphic symptoms were randomly assigned to one of the two trainings. Our second study (n = 58 adults with body dysmorphic symptoms) evaluated an extended 2-week stand-alone self-esteem training.

RESULTS

In the first study, self-esteem in different domains (appearance, performance and social), self-focused attention, and BDD symptom severity improved in both groups. Other-focused attention only increased in the attention training group. Participants' overall adherence was high. In the second study we observed significant improvements in self-esteem, BDD symptom severity, and other secondary outcomes, with additional improvements in most outcomes in the second week. Adherence was again high.

CONCLUSIONS

Together, these findings show that a brief internet-based intervention may be a highly accepted and effective way of improving self-esteem in people suffering from BDD symptoms.

Emotional Regulation as a Transdiagnostic Process of Emotional Disorders in Therapy: A Systematic Review and Meta-Analysis

CONTEXT

Several studies have shown that emotional regulation (ER) is a transdiagnostic construct of emotional disorders. Therefore, if therapy improves ER, it would improve psychological distress.

OBJECTIVE

This review assesses and compares the changes in ER due to psychological treatment in different therapies.

METHODS

A systematic review and meta-analysis of RCTs published in the databases PubMed, PsycINFO and Web of Science was performed. It was registered in PROSPERO under the number CRD42023387317. Two independent experts in the field reviewed the articles.

RESULTS

A total of 18 articles met the criteria for inclusion in the review. Analysis of these studies suggests that in unified protocol (UP), cognitive behaviour therapy, dialectical behaviour therapy (DBT) and mindfulness, there is evidence to support that a moderate effect occurs during treatment. Furthermore, in mindfulness and DBT, the effect was moderate in the follow-up period, while in UP, it was high.

LIMITATIONS

Given the heterogeneity of the applied interventions and the methodological limitations found in the reviewed trials, the results should be interpreted with caution.

CONCLUSIONS

UP, cognitive behaviour therapy, DBT and mindfulness can improve ER after therapy, while UP, DBT and mindfulness in the follow-up period. Other therapies, such as SKY or Flotation REST, require more research.

Transdiagnostic Cognitive Behavioral Psychotherapy: Unified Protocol as an Example

The fact that there are many limitations of the current classification systems led to the emergence of transdiagnostic approaches (TA) that focus on the common psychopathological processes underlying disorders rather than categorical diagnoses. TA focuses on the underlying common psychopathological processes in the emergence and persistence of mental disorders. Thus, even if the disorders are categorically diagnosed differently, it can be determined how they overlap or separate with each other. TA aims to treat mental disorders using these aspects. TA has a flexible and modular structure that can be easily integrated into cognitive behavioral therapies. The rest of this review will focus on the Unified Protocol (UP), one of the most popular TA examples. The main purpose of the UP is to enable patients to recognize their feelings and give more adaptive reactions to their negative emotions. Accordingly, UP consists of eight modules. The modules can usually be completed in a total of 11 - 17 weeks. Each 50 to 60-minute individual session is held once a week. If necessary, changes can be made to the number or the frequency of sessions allocated to modules. The goals of each module of the UP and the treatment approaches towards these goals allow a very clearly defined approach. For this reason, there is a need for a detailed evaluation, conceptualization and treatment plan before the UP is put into practice. We hope that mental health professionals from Turkey will contribute to the developments in the UP.

The Comparative Efficacy of Unified Transdiagnostic Protocol (UP) and Mindfulness-Based Stress Reduction Protocol (MBSR) on Emotion Regulation and Uncertainty Intolerance in Infertile Women Receiving IVF

Some emotional and social aspects of infertility affect the response of the infertile women to the treatment. The purpose of this study was to compare the efficacy of unified transdiagnostic protocol (UP) and mindfulness-based stress reduction protocol (MBSR) on emotion regulation and uncertainty intolerance in infertile women receiving IVF. Forty-five infertile women with symptoms of anxiety and depression were included in the study. They were randomly assigned in two intervention groups and one control group. The UP was performed for 10 sessions and MBSR was performed for eight sessions. All participants completed emotion regulation and uncertainty intolerance questionnaires at pre-test, post-test, and follow-up stages. Both interventions had a significant effect on increasing patients' emotion regulation (p ≤ 0.05), but only unified transdiagnostic protocol had a significant effect on intolerance of uncertainty (p ≤ 0.05). Findings show that UP and MBSR have increased emotion regulation. Also UP could reduce the rate of uncertainty intolerance.

Cognitive-behavioral and related therapies for obsessive-compulsive and related disorders

PURPOSE OF REVIEW

Cognitive behavioral therapy (CBT) with exposure and response prevention is the first-line treatment for obsessive-compulsive disorder (OCD) and related disorders such as body dysmorphic disorder (BDD). We review here recent developments in CBT and related therapies in treating OCD and related disorders.

RECENT FINDINGS

Superiority of CBT over medications in treating OCD is being questioned by some recent meta-analyses, nonetheless CBT continues to be the mainstay of treatment. Web-based therapies have been shown to be beneficial in treating at least mild-to-moderately ill patients. Mindfulness-based CBT, intensive residential treatment and Bergen 4-day concentrated exposure are also proving to be useful in treating OCD. Large well designed studies have demonstrated the efficacy CBT over supportive therapy in treating BDD. Research on the efficacy of CBT in treating hoarding disorder is accumulating.

SUMMARY

Efficacy of web-based CBT has a potential public health importance in that CBT may now become accessible to all and benefit at least mild-to-moderately ill patients who form most of the clinically ill sample. Similarly, efficacy of Bergen 4-day concentrated exposure will have a huge public health implication if the findings can be replicated in other centers across the world.

The comorbidity structure of fear, distress and compulsive disorders in an acute psychiatric sample

Body dysmorphic disorder (BDD) and obsessive-compulsive disorder (OCD), collectively referred to as compulsive disorders, have typically not been included in structural research on the internalizing spectrum due to low prevalence in community samples. The current study examined the higher-order structure of anxiety, depressive and compulsive disorders among patients in a psychiatric partial hospital program (N = 2,178). We applied confirmatory factor analysis to diagnostic data obtained at admission and compared several competing models of the comorbidity structure. A one-factor model accounted well for the co-occurrence of all the disorders. A two-factor model comprised of fear and distress factors, wherein compulsive disorders loaded on fear, also fit the data well. However, a very large factor correlation (r = 0.86) suggested limited discriminant validity of fear and distress in the sample. Alternate models that featured a distinct compulsivity factor were not viable owing to large correlations between fear and compulsive disorders. Overall, our findings indicate that a broad internalizing dimensions underlies not only anxiety and depression, but also compulsive disorders, in an acute psychiatric population. Future studies using symptom-level data are needed to replicate these results and determine the structure of internalizing disorders from the bottom up, starting with narrowly defined symptom components.

The comparison between CBT focused on perfectionism and CBT focused on emotion regulation for individuals with depression and anxiety disorders and dysfunctional perfectionism: a randomized controlled trial

BACKGROUND

There is considerable evidence indicating that similar aetiological and maintenance processes underlie depressive and anxious psychopathology. According to the literature, perfectionism and emotion regulation are two transdiagnostic constructs associated with symptoms of emotional disorders.

AIMS

This study is the first randomized controlled trial comparing the efficacy of cognitive behavioural therapy for perfectionism (CBT-P) and the unified protocol for the transdiagnostic treatment of emotional disorders (UP).

METHOD

Seventy-five participants with a range of depressive and anxiety disorders and elevated perfectionism were randomized to three conditions: CBT-P, UP or a waitlist control (WL).

RESULTS

Repeated measures ANOVA indicated that the treatment groups reported a significantly greater pre-post reduction in the severity of symptoms of disorders, as well as a significantly greater pre-post increase in quality of life, all with moderate to large effect sizes compared with the WL group. Treatment gains were maintained at 6-month follow-up. The CBT-P group reported a significantly greater pre-post reduction in perfectionism compared with UP, and the UP group reported a significantly greater pre-post improvement in emotion regulation compared with CBT-P.

CONCLUSIONS

Findings support CBT for perfectionism and regard UP as efficacious treatments for individuals with depression and anxiety disorders who also have dysfunctional perfectionism. It appears that perfectionism cannot be a serious obstacle to UP. As this is a preliminary study and has some limitations, it is recommended that further research be conducted.

Transdiagnostic treatment of emotional disorders in people with multiple sclerosis: randomized controlled trial

BACKGROUND

Multiple sclerosis (MS) is a neurodegenerative disease of the central nervous system. MS is significantly associated with a high rate of psychological, behavioral, and emotional consequences. Despite the frequent mental disorders, high rate of psychological comorbidities, and emotional problems in people with MS (PwMS), these conditions are often underdiagnosed and undertreated. This study aimed to examine the efficacy of a group format of the unified protocol for the transdiagnostic treatment of emotional disorders in adult PwMS associated with an emotional disorder.

METHODS

Seventy adult PwMS were randomized using an internet-based computer system to either the unified protocol (n = 35) or treatment as usual condition. The assessment protocol included semi-structured clinical interviews and self-reports evaluating diagnostic criteria, depression, anxiety and worry symptoms, emotional dysregulation, and affectivity.

RESULTS

The parametric test of analysis of covariance, followed the intent to treat analyses, revealed the unified protocol significantly changed depression symptoms (Cohen's d = 1.9), anxiety symptoms (Cohen's d = 2.16), worry symptoms (Cohen's d = 1.27), emotion dysregulation (Cohen's d = 0.44), positive affect (Cohen's d = 1.51), and negative affect (Cohen's d = 1.89) compared with the control group. The unified protocol also significantly improved outcome scores at the end of treatment relative to baseline (p < .001).

CONCLUSION

The findings support that the unified protocol could be an additional efficient psychological treatment for PwMS. Trial registration IRCT, number: IRCT20190711044173N1. Registered 31october 2019, https://en.irct.ir/user/trial/40779/view .

Transdiagnostic treatment of emotional disorders for women with multiple sclerosis: a randomized controlled trial

BACKGROUND

Multiple sclerosis (MS) is a chronic, unpredictable, neurodegenerative disease, significantly associated with psychological, behavioral, cognitive, and emotional consequences. MS is more common in females than males and frequently affects women during their reproductive years. Despite the frequent mental disorders, comorbidities, and emotional problems in People with MS (PwMS), these conditions are too often underdiagnosed and undertreated.

OBJECTIVE

This study aimed to examine the efficacy of a group format of the Unified Protocol (UP) for the Transdiagnostic treatment of depression and anxiety disorders in females with MS.

METHODS

In the present study, Sixty-four adult females diagnosed with MS were randomized to either the UP (n = 32) or treatment-as-usual conditions. The assessment protocol included semi-structured clinical interviews and self-reports evaluating diagnostic criteria, depression, anxiety and worry symptoms, emotional regulation, and affectivity.

RESULTS

Repeated measure analysis of variance (ANOVA) revealed that the UP significantly improved depression scores [Cohen's d = - 2.11, 95% CI (- 2.72, - 1.50)], anxiety scores [Cohen's d = - 3.34, 95% CI (- 4.01, - 2.58)], positive and negative affect scale (PANAS)-positive affect scores [Cohen's d = 1.46, 95% CI (1.46, 2.01)], PANAS-negative affect scores [Coen's d = - 2.21, 95% CI (- 2.84, - 1.60)], difficulties emotion regulation scale scores [Cohen's d = 1.40, 95% CI (- 0.87, - 0.03)], and Worry scale scores [Cohen's d = - 0.45, 95% CI (- 0.95, - 0.04)] at the end of treatment relative to compared to the control condition. Also, treatment gains were maintained at the three-month follow-up (p < 0.001).

CONCLUSION

The findings provide the support that the UP could be an additional efficient psychological treatment for females with MS. ISRCTN Number: ISRCTN95459505.

Transdiagnostic treatment of emotional disorders in people with multiple sclerosis: randomized controlled trial

Background

Multiple sclerosis (MS) is a neurodegenerative disease of the central nervous system. MS is significantly associated with a high rate of psychological, behavioral, and emotional consequences. Despite the frequent mental disorders, high rate of psychological comorbidities, and emotional problems in people with MS (PwMS), these conditions are often underdiagnosed and undertreated. This study aimed to examine the efficacy of a group format of the unified protocol for the transdiagnostic treatment of emotional disorders in adult PwMS associated with an emotional disorder.

Methods

Seventy adult PwMS were randomized using an internet-based computer system to either the unified protocol (n = 35) or treatment as usual condition. The assessment protocol included semi-structured clinical interviews and self-reports evaluating diagnostic criteria, depression, anxiety and worry symptoms, emotional dysregulation, and affectivity.

Results

The parametric test of analysis of covariance, followed the intent to treat analyses, revealed the unified protocol significantly changed depression symptoms (Cohen’s d = 1.9), anxiety symptoms (Cohen’s d = 2.16), worry symptoms (Cohen’s d = 1.27), emotion dysregulation (Cohen’s d = 0.44), positive affect (Cohen’s d = 1.51), and negative affect (Cohen’s d = 1.89) compared with the control group. The unified protocol also significantly improved outcome scores at the end of treatment relative to baseline (p < .001).

Conclusion

The findings support that the unified protocol could be an additional efficient psychological treatment for PwMS.

Trial registration IRCT, number: IRCT20190711044173N1. Registered 31october 2019, https://en.irct.ir/user/trial/40779/view.

Dysmorphic concern and behavioural impairment related to body image in adolescents

This study examined a moderated mediation model testing whether dysmorphic concern is related to behaviour altered to change appearance. This relationship is potentially mediated by depressive symptomatology (dysphoria and self-esteem) and ideas of reference about "laughing, commenting" and "attention, appearance," and each mediated relationship moderated by sex. The sample was made up of 3377 adolescents from 12 to 18 years old (Mage  = 14.52; SD = 1.65, 56.5% girls). The results showed that dysphoria and ideas of reference about "laughing, commenting" and "attention, appearance" partially mediated the relationship between dysmorphic concern and behavioural impairment related to body image. The relationship with dysphoria was moderated by sex, such that the mediation effect was stronger in girls than in boys. This result implies that girls who are worried about some characteristic of their appearance and show dysphoria are at greater risk of altered behaviour involving avoidance or controlling their appearance than boys. In addition, a possible risk of body dysmorphic disorder (3.45% of the sample) was found, with very prominent hiding behaviour using clothing or control behaviours, such as frequent weighing and looking at oneself in the mirror too much. Implications of these findings are discussed.

The dark side of Instagram: Predictor model of dysmorphic concerns

Dysmorphic concern are excessive preoccupation about one or several physical characteristics perceived as defects, usually unnoticeable by others. This study was intended to explore the relationship between Instagram use and dysmorphic concerns through appearance-related comparisons, ideas of reference and problems with emotion regulation, and find out whether this relationship is moderated by gender.

METHOD

The sample was comprised of 796 participants (Mage  = 22.49; SD = 3.56; 54% women).

RESULTS

The results showed a non-significant direct effect between Instagram use and dysmorphic concerns. However, the relationship between these variables was statistically significant through appearance-related comparisons, ideas of reference about "laughing, commenting" and difficulties in emotion regulation. Gender did not moderate any relationship.

CONCLUSIONS

Men and women who made the most use of Instagram were equally vulnerable to dysmorphic concerns when they tended to compare their appearance with other users, had problems regulating their emotions, and showed interpretative biases related to the belief that others could make comments about them or laugh at them because of their imperfections. The implications of the study are discussed.

Acupuncture for emotional disorders in patients with migraine: a systematic review protocol

INTRODUCTION

Migraine is the second-leading cause of years lived with disability worldwide. The high prevalence of migraine-related emotional disorders is often overlooked. Acupuncture is often used to treat both migraine and emotional disorders. This systematic review protocol aims to analyse whether acupuncture is effective for treating emotional disorders in patients with migraine.

METHODS AND ANALYSIS

Nine databases will be searched from inception to may 2019: cochrane central register of controlled trials, medline, embase, allied and complementary medicine database, cinahl, china national knowledge infrastructure, chinese biomedical literature database, vip database and wanfang database. Randomised controlled trials (rcts) of acupuncture therapy for migraine with emotional functioning outcomes, which were reported in chinese or english, will be included. The primary outcome is the change in emotional functioning. Study selection, data extraction and assessment of the risk of bias will be performed independently by two or more reviewers. Revman software (v.5.3) will be used to perform the assessment of the risk of bias and data synthesis.

ETHICS AND DISSEMINATION

Ethics approval is not be needed because the data will not contain individual patient data, and there are no concerns about privacy. The results of this meta-analysis will be disseminated through publication in a peer-reviewed journal or relevant conference.

TRIAL REGISTRATION NUMBER

CRD42019139433.