Psychometric evaluation of the Brown Assessment of Beliefs Scale in body dysmorphic disorder

Long-term outcomes of smartphone-delivered cognitive behavior therapy for body dysmorphic disorder: A one-year naturalistic follow-up

Background

Body dysmorphic disorder (BDD) is an often chronic and impairing psychiatric condition. Research shows that smartphone-delivered cognitive behavior therapy (CBT) with coaching may be a scalable and effective treatment for BDD. However, evidence for long-term gain maintenance is limited.

Objectives

The aim of the current study was to examine the long-term outcomes of a smartphone-based CBT for BDD.

Method

Adults with a primary diagnosis of BDD who completed a 12-week course of smartphone-delivered CBT with coach support were evaluated 3- and 12-months posttreatment. Symptom severity, remission and responder status were assessed with the clinician-rated Yale-Brown Obsessive-Compulsive Scale modified for BDD (BDD-YBOCS). Secondary outcomes were also evaluated and included BDD-related insight, depression, functioning and quality of life. Data were analyzed using four different approaches to missing data, with maximum likelihood estimation as the main approach.

Results

There was significant attrition from posttreatment (n = 57) to 3-month (n = 49) and 12-month (n = 33) follow-up. The mean BDD-YBOCS severity score remained stable during the follow-up period [Estimated Mean (SE) at posttreatment, 3-months, and 12-months = 18.7(1.1), 18.9(1.2) and 18.8(1.3), respectively]. The proportion of participants responding to treatment and in remission remained relatively unchanged as well (63 % responders and 46 % remitters at posttreatment, 54 % and 35 % at 3-month follow-up, and 61 % and 37 % at 12-month follow-up, respectively). Posttreatment gains in BDD-related insight, functioning, and quality of life were maintained; there were small increases in depression (ES = 0.36) from posttreatment to 12-month follow-up.

Conclusions

Improvements after coach-supported smartphone-based CBT for BDD are maintained one year after treatment.

Yale-Brown Obsessive-Compulsive Scale Modified for Body Dysmorphic Disorder: Factor Structure and Construct Validity of Subfactors

The Yale-Brown Obsessive-Compulsive Scale modified for Body Dysmorphic Disorder (BDD-YBOCS) is a semi-structured interview designed to assess the severity of current BDD. The aim of the study was to examine the factor structure and construct validity of the BDD-YBOCS. The sample included 366 adults with BDD who completed the BDD-YBOCS and other measures of BDD severity/impairment, psychiatric distress (i.e., anxiety and depression) and quality of life. Exploratory factor analysis supported two factors that were weakly correlated with each other (r = .21): (1) Severity (i.e., time, distress, interference, and avoidance; 31.6% of the variance) and (2) Resistance/Control (i.e., reduced effort to resist symptoms and lack of control over symptoms; 16.7% of the variance). The Severity factor had good internal consistency (α = .82) and good construct validity (rs = .69-.81 with BDD severity/impairment; rs =.38-.56 with depression and anxiety; and rs = .48-.53 with functional impairment and quality of life). The Resistance/Control factor had acceptable internal consistency (α = .74) but more limited construct validity (rs = .27-.28 with BDD severity/impairment (rs = .04-.20 with depression and anxiety and rs = .05-.14 with functional impairment and quality of life. Implications for the conceptualization and assessment of BDD severity are discussed.

Predicting response to a smartphone-based cognitive-behavioral therapy for body dysmorphic disorder

BACKGROUND

Body dysmorphic disorder (BDD) is a severe, chronic disorder if untreated. Smartphone cognitive behavioral therapy (CBT) for BDD is efficacious and can reduce key treatment barriers (e.g., lack of clinicians, cost, stigma). While promising, little is known about who is more or less likely to benefit from this approach.

METHODS

This is a secondary data analysis of a randomized, waitlist-controlled trial of smartphone CBT for BDD. Participants (N = 80) were recruited nationally and randomized to receive a 12-week, coach-guided CBT for BDD app, either immediately or after a 12-week waitlist. The main outcome for this analysis was BDD severity (BDD-YBOCS) over time (baseline, week 6, week 12) during the active app use phase in each randomized group (n = 74). Secondary outcomes included treatment response (≥30 % reduction in BDD-YBOCS) and remission (total BDD-YBOCS ≤16) at end-of-treatment.

RESULTS

Immediate (vs. delayed) CBT predicted better outcomes (symptom improvement), as did gender identity (symptom improvement), higher baseline treatment credibility and expectancy (response, remission), lower baseline BDD severity (remission), and sexual minority status (vs. heterosexual; response, remission).

LIMITATIONS

Limitations include the relatively small sample, drop-out rate of 22 %, and limited gender and racial-ethnic diversity.

CONCLUSIONS

These results highlight a potential advantage of smartphone CBT in historically marginalized populations, and the importance of efforts to hasten treatment access, bolster confidence in the treatment at treatment onset, and develop stratified care models to optimize treatment allocation and efficacy.

Clinical characteristics among sexual minority and heterosexual women with body dysmorphic disorder

Body dysmorphic disorder (BDD) is a common disorder associated with substantial comorbidity, impairment, and poor quality of life. Research on subcultural variations of BDD is limited but may impact assessment and treatment of the disorder. The current study examined clinical features in a sample of sexual minority (SM; n = 43) and heterosexual (n = 155) women with diagnosed BDD. Participants completed self-report and clinician-administered measures of demographic and clinical characteristics. Results indicated largely similar clinical features across groups with some exceptions: compared to non-SM women, SM women were younger (M = 25.50 vs 31.96 years, p < .001), had better BDD-related insight (M = 14.51 vs 16.26, p = .01), endorsed a greater number of disliked body parts, and were more likely to express preoccupation with body build (OR = 4.6, 95% CI [2.0, 10.9]), chin/jaw (OR = 4.7, 95% CI [2.1, 10.3]), and shoulders (OR = 10.1, 95% CI [2.7, 37.9]), possibly reflecting nuanced beauty ideals within the SM community. There were no significant group differences in other body parts of concern, BDD severity, or depression. Future studies are needed in larger, more inclusive samples to explore the relationship between diverse identities on BDD and its associated features.

A randomized controlled trial of mindfulness-based cognitive therapy for body dysmorphic disorder: Impact on core symptoms, emotion dysregulation, and executive functioning

BACKGROUND AND OBJECTIVES

Mindfulness-based cognitive therapy (MBCT) is garnering increasing empirical interest as an intervention for Body Dysmorphic Disorder (BDD), although no studies of mindfulness as a standalone treatment have included a sample composed entirely of patients with BDD or a comparison group. The aim of this study was to investigate the improvement of MBCT intervention on the core symptoms, emotional dysfunction, and executive function of BDD patients, as well as the feasibility and acceptability of MBCT training.

METHOD

Patients with BDD were randomized into an 8-week MBCT group (n = 58) or treatment-as-usual (TAU) control group (n = 58) and were assessed at pre-treatment, post-treatment, and 3-month follow-up.

RESULTS

Participants who received MBCT showed greater improvement on self-reported and clinician ratings of BDD symptoms, self-reported emotion dysregulation symptoms and executive function compared with TAU participants. Improvement for executive function tasks was partially supported. In addition, feasibility and acceptability of MBCT training were positive.

LIMITATIONS

There is no systematic assessment of the severity of key potential outcome variables associated with BDD.

CONCLUSION

MBCT may be a useful intervention for patients with BDD, improving patients' BDD symptoms, emotion dysregulation, and executive functioning.

Delusional beliefs in adolescents with anorexia nervosa, obsessive-compulsive disorder, or first-episode psychosis: A comparative study

Delusional thinking is a key symptom of first-episode psychosis (FEP), but it has also been studied in obsessive-compulsive disorder (OCD) and anorexia nervosa (AN). This study aimed to analyze the psychometric properties of the Brown Assessment of Beliefs Scale (BABS) in a sample of adolescents diagnosed with a FEP, AN, or OCD, and to compare delusional thinking among the three samples. The sample comprised 60 patients in three groups of 20 diagnosed with OCD, AN, or FEP. Participants underwent assessment by diagnostic interview, the BABS scale, and a measure of depressive symptomatology. Specific instruments were also used to assess the main symptomatology of each disorder. The BABS had good internal consistency, and high validity and reliability. The OCD group scored significantly lower than the other two groups in all scale items except for items 4 (fixation of ideas), 6 (insight), and 7 (delusions of reference). A significant difference only existed between the AN and FEP groups for item 7 (delusions of reference). The BABS scale is a valid and reliable tool for assessing delusionality in adolescents diagnosed with OCD, AN, or FEP, with evidence of marked differences between the disorders. Assessing these symptoms could influence management, helping to improve treatment adherence and prognosis.

Measurement fidelity of clinical assessment methods in a global study on identifying reproducible brain signatures of obsessive-compulsive disorder

OBJECTIVE

To describe the steps of ensuring measurement fidelity of core clinical measures in a five-country study on brain signatures of obsessive-compulsive disorder (OCD).

METHOD

We collected data using standardized instruments, which included the Yale-Brown Obsessive-Compulsive Scale (YBOCS), the Dimensional YBOCS (DYBOCS), the Brown Assessment of Beliefs Scale (BABS), the 17-item Hamilton Depression Scale (HAM-D), the Hamilton Anxiety Scale (HAM-A), and the Structured Clinical Interview for DSM-5 (SCID). Steps to ensure measurement fidelity included translating instruments, developing a clinical decision manual, and continuing reliability training with 11-13 transcripts of each instrument by 13 independent evaluators across sites over 4 years. We use multigroup confirmatory factor analysis (MGCFA) to report interrater reliability (IRR) among the evaluators and factor structure for each scale in 206 participants with OCD.

RESULTS

The overall IRR for most scales was high (ICC > 0.94) and remained good to excellent throughout the study. Consistent factor structures (configural invariance) were found for all instruments across the sites, while similarity in the factor loadings for the items (metric invariance) could be established only for the DYBOCS and the BABS.

CONCLUSIONS

It is feasible to achieve measurement fidelity of clinical measures in multisite, multilinguistic global studies, despite the challenges inherent to such endeavors. Future studies should not only report IRR but also consider reporting methods of standardization of data collection and measurement invariance to identify factor structures of core clinical measures. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Early response to cognitive behavioral therapy for body dysmorphic disorder as a predictor of outcomes

Individuals with body dysmorphic disorder (BDD) suffer from distressing or impairing preoccupations with perceived imperfections in their appearance. This often-chronic condition is associated with significant functional impairment and elevated rates of psychiatric comorbidity and morbidity, including depression, substance use disorders, and suicidality. Cognitive behavioral therapy (CBT) for BDD has been shown to be efficacious. However, this intervention is long (up to 24 weeks) relative to many manualized approaches for other related conditions, there is a significant shortage of clinicians trained in CBT for BDD, and some patients drop out of treatment and/or do not respond. Thus, there is great interest in understanding and predicting who is most likely to respond, to better allocate clinical resources. This secondary data analysis of participants enrolled in prior uncontrolled and controlled studies of CBT for BDD explored whether early response to CBT, operationalized as percentage change in symptom severity within the first four weeks and the first 12 weeks of this 24-week treatment, predicts clinical outcomes for patients with BDD (n = 90). The findings indicated that minimal early symptom change was not indicative of eventual non-response. This suggests that patients and clinicians should not be discouraged by limited early improvement but should instead continue with a full course of treatment before reevaluating progress and alternative interventions. Overall, the results support the view that treatment success is more likely if a longer CBT protocol is followed. More work is needed to understand mechanisms of change and thus match optimal interventions to patient characteristics.

An Evaluation of the Body Dysmorphic Disorder Symptom Scale as a Measure of Treatment Response and Remission in Psychotherapy and Medication Trials

The Body Dysmorphic Disorder Symptom Scale (BDD-SS) is a self-report tool that captures an array of representative behavioral and cognitive symptoms commonly displayed by individuals with BDD. The BDD-SS is regularly used among experts in the field, though its utility as a measure of treatment response has not yet been formally evaluated. Results from two clinical trials of BDD treatment were pooled from an archived database to create a sample of 220 BDD participants who received either psychosocial or medication-based interventions for BDD. We used baseline BDD-SS scores to describe psychometric properties, baseline correlations with other scales to examine the content validity of the BDD-SS, and longitudinal symptom data to evaluate capacity to detect clinically relevant change. Results indicated that the BDD-SS has good psychometric properties and is able to detect symptom change over time, although it showed lower rates of reliable change with treatment relative to the gold standard rater-administered Yale-Brown Obsessive-Compulsive Scale Modified for BDD (BDD-YBOCS). The BDD-SS offers meaningful information about treatment response in a self-report format and may be particularly useful to employ in clinical practice settings as a means of gathering symptom and treatment response data via self-report when rater-administered interviews are not feasible, although it may underestimate the extent of improvement with treatment.

Insight in nonpsychotic disorders: A new model of insight and a systematic review of measures

OBJECTIVE

There is substantial research examining insight in psychotic disorders and in some nonpsychotic disorders. However, there has been little attention given to many nonpsychotic disorders. Research on insight in psychosis distinguishes between cognitive and clinical insight. In most studies examining insight in nonpsychotic disorders, definitions and assessments of insight vary significantly. The purpose of this review is to suggest a definition of insight in nonpsychotic disorders such that it can be used across different disorders.

METHOD

We systematically review the extant literature of insight in nonpsychotic disorders and analyze the assessments used in order to determine how well they capture these two types of insight. Then, we discuss how these two constructs can provide better understanding of the phenomenology of insight in nonpsychotic disorders.

RESULTS

The systematic search resulted in 99 articles. These articles used 17 different methods of measuring insight, containing 127 questions. Results of the content analysis of items suggested that measures of insight used in nonpsychotic disorders do not distinguish between cognitive and clinical insight, but that most questions (90%) can indeed be reliably differentiated.

CONCLUSION

We provide a multidimensional model of cognitive and clinical insight in nonpsychotic disorders, emphasizing the complexity of assessment and the importance of accurately defining insight. Such definitions have important theoretical and clinical implications, offering a better understanding of the concept of insight in nonpsychotic disorders.

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.

Predictors and moderators of symptom change during cognitive-behavioral therapy or supportive psychotherapy for body dysmorphic disorder

BACKGROUND

Research on predictors of treatment outcome in body dysmorphic disorder, a common and severe disorder, is very limited, and no prior studies have examined moderators of outcome. Because treatment is often but not always efficacious, it is important to identify who is more likely to benefit. We examined predictors and moderators of improvement with therapist-delivered cognitive-behavioral therapy versus supportive psychotherapy in the only study of these treatments for body dysmorphic disorder. This report presents secondary analyses from a study whose primary findings have previously been published (Wilhelm et al., 2019).

METHODS

Participants (N=120) with DSM-IV body dysmorphic disorder were randomized to therapist-delivered weekly cognitive-behavioral therapy or supportive therapy for 24 weeks. Using reliable and valid measures, we tested baseline body dysmorphic disorder severity, insight/delusionality, and depression severity as predictors and moderators of overall and treatment modality-specific symptom change. We explored additional variables as predictors and moderators of outcome.

RESULTS

Greater treatment credibility (p=0.02) and presence of obsessive-compulsive personality disorder (p=0.03) predicted greater improvement. Serotonin-reuptake inhibitor treatment at baseline (unchanged during the study) (p=0.01) predicted less improvement. No other variables predicted or moderated outcome (all p>0.05).

LIMITATIONS

The study was not powered a priori to detect predictor or moderation effects, which limited our ability to detect them unless they were strong.

CONCLUSIONS

Because greater treatment credibility predicted better outcomes, fostering credibility during therapy may maximize gains. Improvement was not impeded by more severe body dysmorphic disorder, depressive symptoms, or poorer insight. No variables moderated treatment-specific improvement.

Rates of remission, sustained remission, and recurrence in a randomized controlled trial of cognitive behavioral therapy versus supportive psychotherapy for body dysmorphic disorder

BACKGROUND

Little data exist on remission rates following psychotherapy for body dysmorphic disorder (BDD).

METHODS

Using data from a large study of therapist-delivered cognitive behavior therapy (CBT) versus supportive psychotherapy (SPT) for BDD (N = 120), we estimated remission rates at treatment endpoint, and rates of delayed remission, sustained remission, and recurrence at 6-month follow-up. We also examined improvement in broader mental health outcomes among remitters.

RESULTS

Full or partial remission rates at end-of-treatment were significantly higher following CBT (68%) than SPT (42%). At 6-month follow-up, an additional 10% (CBT) and 14% (SPT) experienced delayed remission, 52% (CBT) and 27% (SPT) experienced sustained remission, and 20% (CBT) and 14% (SPT) experienced recurrence. Remission was never achieved by 18% (CBT) and 45% (SPT). Participants in remission at end-of-treatment experienced significant improvements in functional impairment, depression severity, BDD-related insight, and quality of life compared to nonremitters.

CONCLUSIONS

Full or partial remission rates are high following CBT for BDD and higher than after SPT.

Mechanisms of Change in Cognitive Behavioral Therapy for Body Dysmorphic Disorder

Although cognitive-behavioral therapy (CBT) is highly efficacious for body dysmorphic disorder (BDD), not all patients benefit, and mechanisms underlying response remain unknown. In this first report of the mechanisms underlying improvement with CBT for BDD, we examined whether cognitive (maladaptive beliefs, perfectionism, schemas) and behavioral (checking, grooming, avoidance behaviors) changes mediate the effect of CBT on BDD symptom reduction. Forty-five participants with BDD who enrolled in a CBT for BDD treatment development study were included in two sets of analyses: (1) between-subject mediation of the effect of 12 weeks of CBT versus waitlist, and (2) within-subject mediation of longitudinal change in BDD symptom severity during 24 weeks of CBT. No significant mediators emerged in the between-subject analysis. Checking, grooming, avoidance behaviors, and maladaptive beliefs mediated within-subject improvements over time. Findings suggest that BDD symptom reduction occurs through the very mechanisms that have been hypothesized to maintain BDD in CBT models. Targeting certain cognitive (beliefs about appearance) and behavioral (checking, grooming, and avoidance behaviors) mechanisms in future treatment trials may enhance symptom improvement during CBT. National Clinical Trials Registration Identifier # NCT00106223.

Predictors of Response to Cognitive-Behavioral Therapy for Body Dysmorphic Disorder

Body dysmorphic disorder (BDD) is a common and distressing or impairing preoccupation with a perceived defect in physical appearance. Individuals with BDD engage in time-consuming rituals to check, hide, or "fix" their appearance or alleviate distress. BDD is associated with substantial psychosocial impairment and high rates of depression, hospitalization, and suicidality. Cognitive-behavioral therapy (CBT) is the treatment of choice for BDD, but not everyone benefits. We examined predictors of CBT-related improvement, an important topic that has received very limited investigation. Treatment was delivered in weekly individual sessions over 18-22 weeks. Results indicated that greater motivation/readiness to change (University of Rhode Island Change Assessment Questionnaire), greater treatment expectancy (Treatment Credibility/Expectancy Questionnaire), and better baseline BDD-related insight (Brown Assessment of Beliefs Scale) significantly predicted better CBT response at posttreatment. Baseline BDD symptom severity and depression did not predict outcome, suggesting that even patients with more severe BDD and depressive symptoms can benefit from CBT for BDD. Efforts should be aimed at enhancing readiness to change and confidence in the treatment at treatment onset as well as addressing the poor insight that often characterizes BDD.

Long-Term Outcomes of Cognitive-Behavioral Therapy for Adolescent Body Dysmorphic Disorder

Emerging evidence suggests that cognitive-behavioral therapy (CBT) is an efficacious treatment for adolescent body dysmorphic disorder (BDD) in the short term, but longer-term outcomes remain unknown. The current study aimed to follow up a group of adolescents who had originally participated in a randomized controlled trial of CBT for BDD to determine whether treatment gains were maintained. Twenty-six adolescents (mean age = 16.2, SD = 1.6) with a primary diagnosis of BDD received a course of developmentally tailored CBT and were followed up over 12 months. Participants were assessed at baseline, midtreatment, posttreatment, 2-, 6-, and 12-month follow-up. The primary outcome measure was the clinician-rated Yale-Brown Obsessive-Compulsive Scale Modified for BDD. Secondary outcomes included measures of insight, depression, quality of life, and global functioning. BDD symptoms decreased significantly from pre- to posttreatment and remained stable over the 12-month follow-up. At this time point, 50% of participants were classified as responders and 23% as remitters. Participants remained significantly improved on all secondary outcomes at 12-month follow-up. Neither baseline insight nor baseline depression predicted long-term outcomes. The positive effects of CBT appear to be durable up to 12-month follow-up. However, the majority of patients remained symptomatic and vulnerable to a range of risks at 12-month follow-up, indicating that longer-term monitoring is advisable in this population. Future research should focus on enhancing the efficacy of CBT in order to improve long-term outcomes.

A Pilot Randomized Controlled Trial of Cognitive-Behavioral Therapy for Adolescents With Body Dysmorphic Disorder

OBJECTIVE

Body dysmorphic disorder (BDD) typically starts in adolescence, but evidence-based treatments are yet to be developed and formally evaluated in this age group. We designed an age-appropriate cognitive-behavioral therapy (CBT) protocol for adolescents with BDD and evaluated its acceptability and efficacy in a pilot randomized controlled trial.

METHOD

Thirty adolescents aged 12 to 18 years (mean = 16.0, SD = 1.7) with a primary diagnosis of BDD, together with their families, were randomly assigned to 14 sessions of CBT delivered over 4 months or a control condition of equivalent duration, consisting of written psycho-education materials and weekly telephone monitoring. Blinded evaluators assessed participants at baseline, midtreatment, posttreatment, and at 2-month follow-up. The primary outcome measure was the Yale-Brown Obsessive-Compulsive Scale Modified for BDD, Adolescent Version (mean baseline score = 37.13, SD = 4.98, range = 24-43).

RESULTS

The CBT group showed a significantly greater improvement than the control group, both at posttreatment (time × group interaction coefficient [95% CI] = -11.26 [-17.22 to -5.31]; p = .000) and at 2-month follow-up (time × group interaction coefficient [95% CI] = -9.62 [-15.74 to -3.51]; p = .002). Six participants (40%) in the CBT group and 1 participant (6.7%) in the control condition were classified as responders at both time points (χ(2) = 4.658, p = .031). Improvements were also seen on secondary measures, including insight, depression, and quality of life at posttreatment. Both patients and their families deemed the treatment as highly acceptable.

CONCLUSION

Developmentally tailored CBT is a promising intervention for young people with BDD, although there is significant room for improvement. Further clinical trials incorporating lessons learned in this pilot study and comparing CBT and pharmacological therapies, as well as their combination, are warranted.

CLINICAL TRIAL REGISTRATION INFORMATION

Cognitive-Behaviour Therapy for Adolescents With Body Dysmorphic Disorder; http://www.isrctn.com/; ISRCTN67699666.

The German version of the Brown Assessment of Beliefs Scale (BABS): Development and evaluation of its psychometric properties

Lack of insight and delusional thinking are hallmarks of a series of psychological disorders such as psychotic disorders and body dysmorphic disorder (BDD). The purpose of the present study was to evaluate the German version of the clinician-administered Brown Assessment of Beliefs Scale (BABS; Am J Psychiatry 1998;155:e102-e108), which consists of 7 items assessing the degree of delusionality in the individual's disorder-related belief (e.g., "The person behind me is staring at me", "My nose looks disgusting"). Specifically, the original BABS was translated and back-translated according to established translation guidelines and administered in 70 individuals diagnosed with BDD. Internal consistency as well as convergent and divergent validity was high, suggesting that the German version of the BABS is a reliable and valid instrument to assess delusional thinking in psychological disorders such as BDD.