Prevalence and heritability of body dysmorphic symptoms in adolescents and young adults: a population-based nationwide twin study

Editorial: Body Dysmorphic Disorder in Children and Adolescents: Time to Act

In this issue of the Journal, Krebs et al.1 report on the prevalence of body dysmorphic disorder (BDD) in young people at the population level, addressing several important gaps in the literature. Previous attempts to estimate the prevalence of BDD in young people primarily relied on samples of students or twins, potentially lacking representativeness, and used self-administered instruments for estimation. While these studies employed validated cutoffs, ensuring reasonable sensitivity and specificity, they were unable to fully exclude alternative explanations for symptoms, such as concerns regarding body weight. Krebs et al.1 break new ground by estimating the prevalence of diagnosed BDD in a large general population-based sample, employing a validated diagnostic instrument.

Epidemiology of Body Dysmorphic Disorder and Appearance Preoccupation in Youth: Prevalence, Comorbidity and Psychosocial Impairment

OBJECTIVE

Little is known about how common and impairing body dysmorphic disorder (BDD) is in the general population of youth. We evaluated the prevalence, comorbidity, and psychosocial impairment associated with BDD and more broadly defined appearance preoccupation in young people.

METHOD

Data were drawn from the 2017 Mental Health of Children and Young People in England survey. BDD and psychiatric comorbidity were assessed in individuals 5 to 19 years of age (N = 7,654) according to DSM-5 criteria, using a clinician-rated standardized diagnostic assessment. Psychosocial impairment was measured with a quantitative scale and was indexed by reported self-harm and suicide attempts, as well as service use, assessed using structured interviews.

RESULTS

The point prevalence of BDD was 1.0% (95% CI = 0.8%-1.3%). BDD was significantly more common among adolescents than children (1.9 vs 0.1%; OR = 22.5, p < .001), and among female than male participants (1.8% vs 0.3%; OR = 7.3, p < .001). Approximately 70% of young people with BDD had psychiatric comorbidity, most commonly internalizing disorders. BDD was associated with self- and parent-reported psychosocial impairment, self-harm and suicide attempts, and service utilization. Appearance preoccupation was more common than full-syndrome BDD, but showed similar age and sex effects, patterns of comorbidity, and associated impairment.

CONCLUSION

BDD and appearance preoccupation are relatively common, especially among adolescent girls, and are associated with substantial co-occurring psychopathology, impairment, and risk. Improved screening is needed to increase detection and diagnosis of BDD, and to facilitate access to evidence-based treatment.

STUDY PREREGISTRATION INFORMATION

The epidemiology of body dysmorphic disorder the youth: prevalence, comorbidity and psychosocial impact; https://osf.io/g83jy.

Examining the association of structural stigmas with body image-related outcomes among sexual minority individuals

Sexual minority individuals display heightened body image disturbance, which is associated with negative health outcomes. Structural stigmas are associated with negative health outcomes among sexual minority individuals, but the association between structural stigmas and body image is not understood. Using a linear regression approach, we examined how U.S. state-level structural racism and structural sexual minority stigma were associated with body image-related outcomes including eating pathology, appearance and/or performance-enhancing drug (APED) misuse, and dysmorphic concern. Participants were 942 cisgender sexual minority individuals ages 18-30, with approximately equal representation among non-Hispanic/Latinx White, Black, Asian, and Hispanic/Latinx individuals. There was not a significant main effect of state-level structural sexual minority stigma on body image-related outcomes. In states with higher structural racism, Hispanic/Latinx participants endorsed higher APED misuse, and this interaction was not significant among non-Hispanic/Latinx White individuals. This pattern was not found among Black or Asian participants, nor was it replicated for dysmorphic concern or eating pathology. Findings suggest that reducing exposure to structural racism could reduce APED misuse among Hispanic/Latinx individuals.

Therapist-guided, Internet-delivered cognitive behaviour therapy for adolescents with body dysmorphic disorder: A feasibility trial with long-term follow-up

Body dysmorphic disorder (BDD) is a prevalent and impairing psychiatric condition that typically debuts in adolescence and is associated with risky behaviours. The disorder can be effectively treated with cognitive behaviour therapy (CBT). However, CBT for BDD is seldom available primarily due to a shortage of trained therapists. Internet-delivered CBT (ICBT) can be a way to increase treatment availability. The aim of this feasibility trial was to evaluate the feasibility, safety, and preliminary efficacy of a CBT protocol for adolescents with BDD, adapted to be delivered over the Internet with minimal therapist support. A total of 20 participants (12-17-year-olds) meeting criteria for BDD were recruited nationally to a specialist outpatient clinic in Stockholm, Sweden. One participant withdrew consent and their data could not be analysed. Nineteen participants were offered 12 modules of therapist-guided ICBT for BDD and were followed up to 12 months post-treatment. Preliminary efficacy was measured at the a priori primary endpoint (3-month follow-up) and at the 12-month follow-up with the clinician-rated Yale-Brown Obsessive Compulsive Scale Modified for BDD for Adolescents. The treatment was rated as both credible and satisfactory and was associated with a large and statistically significant reduction in BDD symptom severity (d = 2.94). The proportion of participants classified as responders at the primary endpoint was 73.7%, and the proportion of full or partial remitters was 63.2%. The average therapist support time was 8 min per participant per week. Treatment gains continued to accrue up to the 12-month follow-up. Two participants attempted suicide and another two reported non-suicidal self-injuries during the study period. ICBT with minimal therapist support is a feasible, potentially efficacious, and durable treatment for adolescents with BDD. Risky behaviours typical of this patient group should be carefully monitored during treatment.

Body Dysmorphic Disorder in Women

Body dysmorphic disorder (BDD) consists of distressing or impairing preoccupation with perceived defects in physical appearance that are actually nonexistent or only slight. This common and often-severe disorder, which affects more women than men, frequently goes unrecognized. BDD is associated with marked impairment in functioning, poor quality of life, and high rates of suicidality. Most patients seek cosmetic treatment, which virtually never improves BDD symptoms. In contrast, serotonin-reuptake inhibitors, often at high doses, and cognitive behavioral therapy that is tailored to BDD's unique clinical features are often effective. This article provides a clinical overview of BDD, including BDD in women.

Body Dysmorphic Disorder

This article summarizes current knowledge of body dysmorphic disorder across the life span. An overview of the epidemiology and phenomenology of this condition is provided, as well as clinical perspectives on assessment and treatment. Barriers to accessing treatment are considered, along with recent developments to improve access. Future directions in research and clinical care for this population are summarized.

Genomics of Obsessive-Compulsive Disorder and Related Disorders: What the Clinician Needs to Know

A wealth of evidence has shown that genetics plays a major role in susceptibility to obsessive-compulsive disorder (OCD) and all of its related disorders. Several large-scale, collaborative efforts using modern genomic methods are beginning to reveal the genetic architecture of these traits and identify long-sought risk genes. In this article, we summarize current OCD and related disorder genomic knowledge and explain how to communicate this information to patients and their families. The article concludes with a discussion of how genomic discovery in OCD and related disorders can inform our understanding of disease etiology and provide novel targets for therapeutic development.

Body image and self-perception in women with navel piercings

The present study investigated how women’s body image and body-perceptual processes are affected by navel piercings, an embellishment of the abdominal region women often feel negatively about. We probed perceptual (response times), cognitive (surveys), affective (aesthetic ratings) and neural (event-related potentials, ERPs) facets of (own) body perception. We found that navel piercings are primarily motivated by the desire to enhance one’s body image, and can significantly improve bodily self-perception relative to before and to imagined removal of the piercing. Hence, body image concerns in women with navel piercings were found to be comparable to those of a control group; and their aesthetic ratings of other women’s abdomens only differed, positively, for images depicting navel piercings. ERPs indicated that the sight of navel piercings enhances early structural encoding of bodies as well as late emotional-motivational processes, especially in women with navel piercings. We further found a strong self-advantage in both cortical and behavioural responses during recognition of own and others’ abdomens, especially for images displaying the piercing. Altogether, findings suggest that navel piercings become strongly, and beneficially, integrated into women’s bodily self image. Such piercings may thus be seen as expressions of body care that can protect against self-harming thoughts and behaviours.

Body-dysmorphic, hoarding, hair-pulling, and skin-picking symptoms in a large sample of adolescents

Few studies have investigated body-dysmorphic, hoarding, hair-pulling, and skin-picking symptoms in adolescents and how they relate to mental health, quality of life, suicide attempts, and non-suicidal self-harm. We used a quota sampling procedure and contacted 100 secondary centres in the Southeast of Spain, of which 34 participated in the study. A sample of 5,345 adolescents (12–18 years) completed dimensional measures of body-dysmorphic, hoarding, hair-pulling, and skin-picking symptoms. The proportion of adolescents with clinically significant symptoms within each symptom type was estimated and associations with other indicators of mental health examined. Clinically significant body-dysmorphic symptoms were reported by 3.7%, hoarding by 0.9%, hair-pulling by 0.7%, and skin-picking by 1.8%. Body-dysmorphic symptoms were more common in girls and in those over 14 years of age. Body-dysmorphic, hoarding, hair-pulling, and skin-picking symptoms were moderately to strongly associated with obsessive-compulsive symptoms, internalizing symptoms, externalizing symptoms, and poor quality of life. Those with significant body-dysmorphic, hoarding, hair-pulling, and skin-picking symptoms were much more likely to have attempted suicide and engaged in non-suicidal self-harm during the last twelve months than those without such symptoms. Body-dysmorphic symptoms showed the strongest associations with internalizing symptoms and poor quality of life. Limitations are the sole use of self-report and a sample from only two regions in Spain, but findings suggest that body-dysmorphic, hoarding, hair-pulling, and skin-picking symptoms are common and impairing during adolescence.

The association between body dysmorphic symptoms and suicidality among adolescents and young adults: a genetically informative study

BACKGROUND

Previous research indicates that body dysmorphic disorder (BDD) is associated with risk of suicidality. However, studies have relied on small and/or specialist samples and largely focussed on adults, despite these difficulties commonly emerging in youth. Furthermore, the aetiology of the relationship remains unknown.

METHODS

Two independent twin samples were identified through the Child and Adolescent Twin Study in Sweden, at ages 18 (N = 6027) and 24 (N = 3454). Participants completed a self-report measure of BDD symptom severity. Young people and parents completed items assessing suicidal ideation/behaviours. Logistic regression models tested the association of suicidality outcomes with: (a) probable BDD, classified using an empirically derived cut-off; and (b) continuous scores of BDD symptoms. Bivariate genetic models examined the aetiology of the association between BDD symptoms and suicidality at both ages.

RESULTS

Suicidal ideation and behaviours were common among those with probable BDD at both ages. BDD symptoms, measured continuously, were linked with all aspects of suicidality, and associations generally remained significant after adjusting for depressive and anxiety symptoms. Genetic factors accounted for most of the covariance between BDD symptoms and suicidality (72.9 and 77.7% at ages 18 and 24, respectively), but with significant non-shared environmental influences (27.1 and 22.3% at ages 18 and 24, respectively).

CONCLUSIONS

BDD symptoms are associated with a substantial risk of suicidal ideation and behaviours in late adolescence and early adulthood. This relationship is largely explained by common genetic liability, but non-shared environmental effects are also significant and could provide opportunities for prevention among those at high-risk.

Body dysmorphia in common skin diseases: Results of an observational, cross-sectional multi-centre study among dermatological out-patients in 17 European countries

BACKGROUND

Body dysmorphic disorder (BDD) is a common psychiatric disorder associated with high costs for healthcare systems as patients may repeatedly ask for different, often not effective interventions. BDD symptoms are more prevalent in patients with dermatological conditions than the general population, but there are no large sample studies comparing the prevalence of BDD symptoms between patients with dermatological conditions and healthy skin controls.

OBJECTIVES

To compare the prevalence of BDD symptoms between patients with different dermatological conditions and healthy skin controls and to describe sociodemographic, physical and psychological factors associated with BDD symptoms to identify patients who may have a particularly high chance of having this condition.

METHODS

This observational cross-sectional, comparative multi-centre study included 8295 participants: 5487 consecutive patients with different skin diseases (56% female) recruited among dermatological out-patients at 22 clinics in 17 European countries and 2808 healthy skin controls (66% female). All patients were examined by a dermatologist. BDD symptoms were assessed by the Dysmorphic Concern Questionnaire (DCQ). Sociodemographic data, information on psychological factors and physical conditions were collected. Each patient was given a dermatological diagnosis according to ICD-10 by a dermatologist.

RESULTS

The participation rate of invited dermatological patients was 82.4% on average across all centres. BDD symptoms were five times more prevalent in patients with dermatological conditions than in healthy skin controls (10.5% vs. 2.1%). Patients with hyperhidrosis, alopecia and vitiligo had a more than eleven-fold increased chance (adjusted Odds Ratio (OR) > 11) of having BDD symptoms compared to healthy skin controls, and patients with atopic dermatitis, psoriasis, acne, hidradenitis suppurativa, prurigo and bullous diseases had a more than six-fold increased chance (adjusted OR > 6) of having BDD symptoms. Using a logistic regression model, BDD symptoms were significantly related to lower age, female sex, higher psychological stress and feelings of stigmatisation.

CONCLUSIONS

This study reveals that clinical BDD symptoms are significantly associated with common dermatological diseases. As such symptoms are associated with higher levels of psychological distress and multiple unhelpful consultations, general practitioners and dermatologists should consider BDD and refer patients when identified to an appropriate service for BDD screening and management.

Clinical characteristics of 172 children and adolescents with body dysmorphic disorder

Body dysmorphic disorder (BDD) often starts in childhood, with most cases developing symptoms before age 18. Yet, BDD research has primarily focused on adults. We report the clinical characteristics of the world's largest cohort of carefully diagnosed youths with BDD and focus on previously unexplored sex and age differences. We systematically collected clinical data from 172 young people with BDD consecutively referred to 2 specialist pediatric obsessive-compulsive and related disorders outpatient clinics in Stockholm, Sweden and in London, England. A series of clinician-, self-, and parent-reported measures were administered. The cohort consisted of 136 girls, 32 boys, and 4 transgender individuals (age range 10-19 years). The mean severity of BDD symptoms was in the moderate to severe range, with more than one third presenting with severe symptoms and more than half showing poor or absent insight/delusional beliefs. We observed high rates of current psychiatric comorbidity (71.5%), past or current self-harm (52.1%), suicide attempts (11.0%), current desire for cosmetic procedures (53.7%), and complete school dropout (32.4%). Compared to boys, girls had significantly more severe self-reported BDD symptoms, depression, suicidal thoughts, and self-harm. Compared to the younger participants (14 or younger), older participants had significantly more severe compulsions and were more likely to report a desire for conducting cosmetic procedures. Adolescent BDD can be a severe and disabling disorder associated with significant risks and substantial functional impairment. The clinical presentation of the disorder is largely similar across sexes and age groups, indicating the importance of early detection and treatment. More research is needed specifically focusing on boys and pre-pubertal individuals with BDD.

Body dysmorphic disorder and depression among male undergraduate students in a Malaysian University

INTRODUCTION

Body dysmorphic disorder (BDD) and depression have been reported to be both prevalent among young people worldwide, resulting in serious implications in their quality of life and social functioning. This is worrying especially in men where mental disorders are often overlooked and under-researched. This study aims to determine the proportion of male university students with symptoms suggestive of body dysmorphic disorder and depression, as well as their perception on their body image.

METHODS

In this cross-sectional study, 1,308 male students between the aged of 17-26 years in a private university in Malaysia via self-administered online questionnaire comprising the Patient Health Questionnaire (PHQ)-9, the Body Dysmorphic Disorder Questionnaire (BQQD) and the Body Self-Image Questionnaire (BSIQ), in addition to their sociodemographic parameters. Data analyses were performed with Mann Whitney test, chi square test and Fisher's exact test.

RESULTS

3.3 and 54.2% of the students had symptoms suggestive of BDD and depression respectively, with up to 9.02% of the students reporting having moderate to severe depression. There was a significant association between BDD symptoms and students staying alone, whilst depression was significantly associated with studying in the rural campus. Furthermore, a significant association was demonstrated between presence of BDD and depression symptoms. Most of the students were dissatisfied with their whole body, especially their height.

CONCLUSION

The proportion of BDD and depression symptoms among male students in our university is quite high. Universities and the public health sector should develop better support service targeting male university students.

Body Dysmorphic Disorder: Clinical Overview and Relationship to Obsessive-Compulsive Disorder

Body dysmorphic disorder (BDD), characterized by a distressing or impairing preoccupation with nonexistent or slight defects in appearance, is associated with markedly poor quality of life and high rates of suicidality. Onset of BDD is usually in childhood or adolescence and, unless appropriately treated, tends to be chronic. The first-line pharmacologic approach for both delusional and non-delusional BDD is serotonin reuptake inhibitors (SRIs), often at high doses. SRI augmentation and switching strategies can be effective. The first-line psychotherapy is cognitive-behavioral therapy (CBT) tailored to BDD's unique clinical features. Cosmetic treatment (such as surgery or dermatologic treatment), although received by a majority of patients with BDD, is not recommended. BDD has many similarities to obsessive-compulsive disorder (OCD) and appears closely related to OCD but also has some important differences. This article, which updates a 2015 article on BDD that we published in this journal, provides a clinically focused overview of BDD and its relationship to OCD.

Bidirectional Behavioral Selection in Mice: A Novel Pre-clinical Approach to Examining Compulsivity

Obsessive-compulsive disorder (OCD) and related disorders (OCRD) is one of the most prevalent neuropsychiatric disorders with no definitive etiology. The pathophysiological attributes of OCD are driven by a multitude of factors that involve polygenic mechanisms, gender, neurochemistry, physiological status, environmental exposures and complex interactions among these factors. Such complex intertwining of contributing factors imparts clinical heterogeneity to the disorder making it challenging for therapeutic intervention. Mouse strains selected for excessive levels of nest- building behavior exhibit a spontaneous, stable and predictable compulsive-like behavioral phenotype. These compulsive-like mice exhibit heterogeneity in expression of compulsive-like and other adjunct behaviors that might serve as a valuable animal equivalent for examining the interactions of genetics, sex and environmental factors in influencing the pathophysiology of OCD. The current review summarizes the existing findings on the compulsive-like mice that bolster their face, construct and predictive validity for studying various dimensions of compulsive and associated behaviors often reported in clinical OCD and OCRD.

A cascade of rejection and appearance preoccupation: Adolescents' body dysmorphic symptoms and appearance rejection sensitivity over 4 years

Adolescence is a high-risk period for body image disturbance and appearance concerns. In a cascade model, we examined interrelations of body dysmorphic symptoms (BDS) with appearance rejection sensitivity (ARS) and tested gender moderation. Participants were 397 Australian adolescents (T1 Mage = 11.7, SD = 0.91; 56% girls) who completed six surveys over 4 years. In a random-intercept cross-lag model, two (of five possible) paths showed ARS predicted higher subsequent BDS, and three (of five possible) paths showed BDS predicted higher subsequent ARS. Girls reported more BDS and ARS than boys, and random intercepts of BDS and ARS were correlated with the correlation stronger in girls than boys. Cross-lag BDD-ARS associations over the six waves were not significantly moderated by gender. Overall, girls are at higher risk of appearance concerns than boys, but BDD-ARS cascade effects do not differ between girls and boys.

Family accommodation in pediatric body dysmorphic disorder: A qualitative study

Family accommodation (FA) is significant in a range of disorders, yet it has never been explored in body dysmorphic disorder (BDD). Interviews were conducted with five young people with BDD, five parents, and five clinicians to explore the types, impact, and purpose of FA in BDD. Every participant reported significant FA of BDD, and the types reported were broadly similar to those found in other disorders. Reassurance giving/seeking and engagement in rituals were the two most common forms of FA reported with funding products being the third. Unsurprisingly, the driver for FA was to reduce the young person's distress and risk. Every participant commented on the negative impact FA had, including the financial burden, social implications, emotional well-being of family members, relationships, and conflict within the family, yet all young people also thought there were positive aspects to FA. Findings are discussed in the context of the limitations of this study.

Body dysmorphic disorder in children and young people

The incidence of body dysmorphic disorder (BDD) in young people is increasing. Causes of BDD are related to the prevalence of social media and adolescent development, especially the role that brain neuroplasticity has on influencing perception. There are long-term impacts of BDD, including depression and suicide. Prevention and promotion of positive body image are part of the nurse's role; treatment can prevent unnecessary aesthetic surgical interventions.

Genetics of OCD and Related Disorders; Searching for Shared Factors

Obsessive compulsive disorder (OCD) and several other obsessive-compulsive related disorders (OCRDs) including hoarding disorder, body dysmorphic disorder (BDD), skin picking disorder, trichotillomania and the newly arising public health conditions of online gaming and gambling disorders, under the umbrella of Problematic Usage of the Internet (PUI), not only share some common phenotypes, but there is evidence to suggest share some genetic risk factors. The simple fact that these disorders segregate within families points to this notion. However, the current data are still scarce. This chapter focuses on identifying the shared genetic factors. To address this question, a systematic review of the literature investigating genetic findings in OCD and OCRDs including PUI was conducted, with a focus on their genetic similarities. Greater knowledge of the specific genetic risks shared among OCRDs would be expected to open new avenues in the understanding of the biological mechanisms causing the development of these phenotypes, as well as provide opportunities to develop new animal and cellular models testing new therapy avenues.

The Dysmorphic Concern Questionnaire: Measurement invariance by gender and race/ethnicity among sexual minority adults

Sexual minority adults report heightened body image disturbances, and may be more likely to meet criteria for body dysmorphic disorder (BDD) than their heterosexual counterparts. Given the poor outcomes associated with BDD, it is important to validate measures assessing dysmorphic symptoms among this at-risk group. The Dysmorphic Concern Questionnaire (DCQ) is a seven-item self-report measure intended to assess dysmorphic symptoms. The present study investigated racial, ethnic, and gender measurement invariance properties of the DCQ in a racially and ethnically diverse sample of sexual minority adults. The current results lend initial support for use of the DCQ to potentially detect BDD symptoms among White, Black, Latino, and Asian sexual minority men and women. This may inform future studies that wish to utilize the DCQ, such as investigations of mean level differences in dysmorphic concern. These findings may have important clinical applications, given the heightened risk of appearance-related concerns among diverse sexual minority adults.

Sudden Gains in Internet-Based Cognitive Behavior Therapy for Body Dysmorphic Disorder

Sudden gains have been associated with better short- and long-term treatment outcomes in a number of psychiatric disorders. However, no studies to date have evaluated sudden gains in body dysmorphic disorder (BDD). We used data from a previous randomized controlled trial evaluating the efficacy of an Internet-based cognitive-behavior treatment (CBT) for BDD. The sample consisted of 47 adults diagnosed with BDD. We compared the treatment outcomes of sudden gainers vs. gradual gainers (i.e., treatment responders with no sudden gains) and non-sudden gainers (i.e., gradual gainers plus nonresponders) at posttreatment and 3, 12, and 24 months after the end of the treatment. Twelve (25.5%) participants experienced a sudden gain. Compared to non-sudden gainers and to gradual gainers, sudden gainers showed significantly larger improvements on the Yale-Brown Obsessive-Compulsive Scale modified for BDD at posttreatment (g = 1.23 and g = .91, respectively), and at 3-month (g = 1.23 and g = 1.00, respectively), 12-month (g = 1.12 and g = .91, respectively), and 24-month follow-up (g = 1.11 and g = .97, respectively). This translated into higher rates of treatment responders and remitters in the sudden gainers across all time points. The occurrence of sudden gains in Internet-based CBT for BDD is associated with favorable short- and long-term treatment outcomes. This suggests that a sudden improvement during the treatment could be a marker of good prognosis, while non-sudden-including gradual-gainers are more likely to need continued support or booster sessions. Early identification of patients who are not progressing as expected and subsequent tailoring of the delivered intervention has the potential to improve treatment outcomes in this group.

Delusional themes in Body Dysmorphic Disorder (BDD): Comparisons with psychotic disorders and non-clinical Controls

The prevailing nosological classification of body dysmorphic disorder (BDD) encompasses an optional specifier "with absent insight/delusional beliefs" for patients who hold high conviction of the veracity of their disorder-specific beliefs. Yet limited research has examined the explicit nature of delusional beliefs in BDD. The current study therefore aimed to compare themes of delusional ideation in BDD relative to schizophrenia (SCZ) and healthy controls (HCs). Participants had a primary diagnosis of BDD (n = 44) or SCZ (n = 55), or were HCs (n = 55) with no personal or immediate family history of a diagnosable mental health disorder. Assessment of multidimensional delusional ideation was based on the Peters Delusional Inventory (PDI). Results showed that BDD and SCZ groups endorsed significantly more items, and had significantly elevated preoccupation and conviction than the HC group. Only the SCZ group exhibited significantly elevated distress relative to HC participants. In addition, BDD (akin to SCZ) participants were more likely to endorse somatic (appearance-related), control and thought alienation themes than the HC group. These findings suggest that delusional beliefs in BDD may not be strictly appearance-related, but rather span broader themes. This conveys therapeutic implications in terms of designing and administering targeted treatments aimed at delusional thinking in BDD.

Prevalence and impact of insomnia in children and adolescents with body dysmorphic disorder undergoing multimodal specialist treatment

Pediatric body dysmorphic disorder (BDD) is challenging to treat. This study aimed to establish the prevalence of insomnia in youth with BDD and explore its impact on clinical outcomes. Sixty-six children and adolescents with BDD consecutively referred to a specialist clinic completed a range of clinical measures, including the Yale-Brown Obsessive-Compulsive Scale Modified for BDD-Adolescent Version (BDD-YBOCS-A), and the Insomnia Severity Index (ISI). Patients with clinical insomnia (ISI score ≥ 9) were compared to the rest of the sample on socio-demographic and clinical features. Fifty-six patients who received multimodal treatment were re-assessed post-treatment. A mixed-model ANOVA was performed to compare treatment outcomes between the insomnia vs. no insomnia groups, and Chi-squared tests were used to compare response and remission rates. According to the ISI, 48% of the sample qualified as having insomnia at baseline. These participants showed significantly higher self-reported BDD symptom severity, more depressive symptoms, and more functional impairment in daily activities. Patients with insomnia improved less on the BDD-YBOCS-A than those without insomnia, although the difference did not reach statistical significance. The rates of responders and remitters were lower in the insomnia group, compared to the non-insomnia group. Insomnia is prevalent in pediatric BDD, and is associated with more severe psychopathology and worse functioning in daily activities. Furthermore, youth experiencing BDD and insomnia may benefit from multimodal treatment to a lesser extent than those without insomnia. If these results are replicated in larger samples, treatment refinements for pediatric BDD could include specific modules to directly target insomnia.

Body dysmorphic disorder and its relationship to sexuality, impulsivity, and addiction

This study sought to examine the prevalence of probable body dysmorphic disorder (BDD) in a university sample and its associated physical and mental health correlates. A 156-item anonymous online survey was distributed via email to a randomly chosen subset of 10,000 university students, at a large public university. The survey queried current use of alcohol and drugs, psychological and physical status, academic performance, sexual behaviors, and questionnaire-based measures of impulsivity and compulsivity. A total of 3,459 participants (59.1% female) completed the survey and were included in the analysis. The overall prevalence of BDD was 1.7% (n = 59). Compared to students without BDD, those with BDD were significantly more likely to endorse symptoms of compulsive sexual behavior, depression, PTSD, and anxiety. Questionnaire-based measures revealed higher levels of both compulsivity and impulsivity associated with BDD. BDD appears to be common in young adults, and is associated with specific mental health comorbidities, as well as both impulsive and compulsive traits. Clinicians should be aware of the presentation of BDD and screen for it in primary care and mental health settings.

Long-term outcome of therapist-guided internet-based cognitive behavioural therapy for body dysmorphic disorder (BDD-NET): a naturalistic 2-year follow-up after a randomised controlled trial

OBJECTIVES

Most patients with body dysmorphic disorder (BDD) do not receive evidence-based treatment. A randomised controlled trial (RCT) has found that a therapist-guided internet-based cognitive-behavioural therapy (CBT) programme for BDD (BDD-NET) can be delivered safely via the internet with significant improvements in BDD symptom severity in the short term. The purpose of this study was to evaluate if the therapeutic gains of BDD-NET are maintained 2 years after treatment.

SETTING

Academic medical centre.

PARTICIPANTS

A naturalistic 2-year follow-up study of the 88 self-referred adult outpatients with a diagnosis of BDD that had received BDD-NET within the context of the RCT.

PRIMARY AND SECONDARY OUTCOMES

The primary outcome was the BDD-Yale-Brown Obsessive-Compulsive Scale (YBOCS). Responder status was defined as a ≥30% reduction in symptoms. Remission was defined as no longer meeting Diagnostic and Statistical Manual of Mental Disorders 5th edition criteria for BDD. Secondary outcomes included measures of depression, global functioning and quality of life.

RESULTS

The efficacy of BDD-NET was sustained long- term, with further improvements observed on the BDD-YBOCS during the follow-up period. At follow-up, 69% (95% CI 57% to 80%) were classified as responders and 56% (95% CI 43% to 69%) were in remission. Gains on depressive symptoms and global functioning were also sustained but not quality of life. A majority of participants reported that the main reason for seeking help for their BDD was the possibility to access the treatment from home.

CONCLUSION

BDD-NET is an effective treatment for BDD, and the patients' gains are maintained in the long term. BDD-NET has the potential to increase access to CBT and may lower the threshold for BDD sufferers to seek help in the first place.

TRIAL REGISTRATION NUMBER

NCT02010619.