Preclinical Alzheimer Disease and the Electronic Health Record: Balancing Confidentiality and Care

Because information technologies are increasingly used to improve clinical research and care, personal health information (PHI) has wider dissemination than ever before. The 21st Century Cures Act in the United States now requires patient access to many components of the electronic health record (EHR). Although these changes promise to enhance communication and information sharing, they also bring higher risks of unwanted disclosure, both within and outside of health systems. Having preclinical Alzheimer disease (AD), where biological markers of AD are identified before the onset of any symptoms, is sensitive PHI. Because of the melding of ideas between preclinical and "clinical" (symptomatic) AD, unwanted disclosure of preclinical AD status can lead to personal harms of stigma, discrimination, and changes to insurability. At present, preclinical AD is identified mainly in research settings, although the consensus criteria for a clinical diagnosis may soon be established. There is not yet adequate legal protection for the growing number of individuals with preclinical AD. Some PHI generated in preclinical AD trials has clinical significance, necessitating urgent evaluations and longitudinal monitoring in care settings. AD researchers are obligated to both respect the confidentiality of participants' sensitive PHI and facilitate providers' access to necessary information, often requiring disclosure of preclinical AD status. The AD research community must continue to develop ethical, participant-centered practices related to confidentiality and disclosure, with attention to sensitive information in the EHR. These practices will be essential for translation into the clinic and across health systems and society at large.

Olfactory and Neuropsychological Functioning in Olfactory Reference Syndrome

BACKGROUND

Olfactory reference syndrome (ORS) is an underrecognized, understudied, and often severe psychiatric disorder characterized by a prominent and distressing or impairing preoccupation with a false belief of emitting an offensive body odor. As this condition has only recently been recognized in the International Classification of Diseases (the 11th Edition), no empirical evidence exists about the underlying features and etiology of the disorder.

OBJECTIVE

To examine the neuropsychological and olfactory functioning of individuals with ORS and address whether there is central nervous system or sensory dysfunction associated with the condition.

METHODS

In this preliminary investigation, 9 consecutive participants with ORS completed a structured clinical interview and neuropsychological and olfaction evaluations.

RESULTS

A proportion of individuals with ORS displayed deficits in aspects of cognitive functioning (i.e., processing speed, executive functioning, recognition memory bias for ORS-related words), olfaction functioning (i.e., odor detection and discrimination), and emotional processing.

CONCLUSIONS

Based on these preliminary findings of cognitive, olfaction, and emotional processing deficits in individuals with ORS, further neuropsychological and olfaction studies are needed that better characterize this understudied patient group and address this study's limitations.

An Updated Sexual Homicide Crime Scene Rating Scale for Sexual Sadism (SADSEX-SH)

The Sexual Homicide Crime Scene Rating Scale for Sexual Sadism (SADSEX-SH) is a rating scale which dimensionally measures the degree of offender sexual sadism in suspected sexual homicide cases. Scoring is accomplished using crime scene and related investigative information. Preliminary norms for the SADSEX-SH prototype indicate that it correctly classified offenders with and without sexual sadism. This study further assessed SADSEX-SH sensitivity, specificity, and inter-rater reliability by comparing a larger sample of male sexual homicide offenders with (n = 20) and without (n = 20) sexual sadism. Two items generally undetectable at crime scenes were removed from the originally proposed 10-item scale, resulting in a final 8-item version. SADSEX-SH total scores for the two groups significantly differed (7.7 ± 3.5, range = 2-14 vs. 2.6 ± 2.0, range = 0-7, t = 5.58, p < .001). Inter-rater reliability was excellent (intraclass correlation coefficients [ICCs] = 0.6-1.0). Using a revised cutoff score of 6, sensitivity was 70.0% and specificity was 90%. This revised scale may prove useful for investigators, clinicians, and institutional professionals in helping to identify and address sexual sadism in sexual homicide offenders.

Pharmacotherapy Relapse Prevention in Body Dysmorphic Disorder: A Double-Blind, Placebo-Controlled Trial

OBJECTIVE

Body dysmorphic disorder is common, distressing, and often severely impairing. Serotonin reuptake inhibitors appear efficacious, but the few existing pharmacotherapy studies were short term (≤4 months), and no relapse prevention studies or continuation phase studies have been conducted to the authors' knowledge. The authors report results from the first relapse prevention study in body dysmorphic disorder.

METHOD

Adults (N=100) with DSM-IV body dysmorphic disorder received open-label escitalopram for 14 weeks (phase 1); 58 responders were then randomized to double-blind continuation treatment with escitalopram versus switch to placebo for 6 months (phase 2). Reliable and valid outcome measures were utilized.

RESULTS

In phase 1, 67.0% of treated subjects and 81.1% of subjects who completed phase 1 responded to escitalopram. Body dysmorphic disorder severity (in both the intent-to-treat and the completer groups) and insight, depressive symptoms, psychosocial functioning, and quality of life significantly improved from baseline to end of phase 1. In phase 2, time to relapse was significantly longer with escitalopram than with placebo treatment (hazard ratio=2.72, 95% CI=1.01-8.57). Phase 2 relapse proportions were 18% for escitalopram and 40% for placebo. Among escitalopram-treated subjects, body dysmorphic disorder severity significantly decreased over time during the continuation phase, with 35.7% of subjects showing further improvement. There were no significant group differences in body dysmorphic disorder severity or insight, depressive symptoms, psychosocial functioning, or quality of life.

CONCLUSIONS

Continuation-phase escitalopram delayed time to relapse, and fewer escitalopram-treated subjects relapsed than did placebo-treated subjects. Body dysmorphic disorder severity significantly improved during 6 additional months of escitalopram treatment following acute response; more than one-third of escitalopram-treated subjects experienced further improvement.

Age at onset and clinical correlates in body dysmorphic disorder

OBJECTIVE

Age at onset is an important clinical feature of all disorders. However, no prior studies have focused on this important construct in body dysmorphic disorder (BDD). In addition, across a number of psychiatric disorders, early age at disorder onset is associated with greater illness severity and greater comorbidity with other disorders. However, clinical correlates of age at onset have not been previously studied in BDD.

METHODS

Age at onset and other variables of interest were assessed in two samples of adults with DSM-IV BDD; sample 1 consisted of 184 adult participants in a study of the course of BDD, and sample 2 consisted of 244 adults seeking consultation or treatment for BDD. Reliable and valid measures were used. Subjects with early-onset BDD (age 17 or younger) were compared to those with late-onset BDD.

RESULTS

BDD had a mean age at onset of 16.7 (SD=7.3) in sample 1 and 16.7 (SD=7.2) in sample 2. 66.3% of subjects in sample 1 and 67.2% in sample 2 had BDD onset before age 18. A higher proportion of females had early-onset BDD in sample 1 but not in sample 2. On one of three measures in sample 1, those with early-onset BDD currently had more severe BDD symptoms. Individuals with early-onset BDD were more likely to have attempted suicide in both samples and to have attempted suicide due to BDD in sample 2. Early age at BDD onset was associated with a history of physical violence due to BDD and psychiatric hospitalization in sample 2. Those with early-onset BDD were more likely to report a gradual onset of BDD than those with late-onset in both samples. Participants with early-onset BDD had a greater number of lifetime comorbid disorders on both Axis I and Axis II in sample 1 but not in sample 2. More specifically, those with early-onset BDD were more likely to have a lifetime eating disorder (anorexia nervosa or bulimia nervosa) in both samples, a lifetime substance use disorder (both alcohol and non-alcohol) and borderline personality disorder in sample 1, and a lifetime anxiety disorder and social phobia in sample 2.

CONCLUSIONS

BDD usually began during childhood or adolescence. Early onset was associated with gradual onset, a lifetime history of attempted suicide, and greater comorbidity in both samples. Other clinical features reflecting greater morbidity were also more common in the early-onset group, although these findings were not consistent across the two samples.

A 4-year prospective observational follow-up study of course and predictors of course in body dysmorphic disorder

BACKGROUND

This report prospectively examines the 4-year course, and predictors of course, of body dysmorphic disorder (BDD), a common and often severe disorder. No prior studies have prospectively examined the course of BDD in individuals ascertained for BDD. Method The Longitudinal Interval Follow-Up Evaluation (LIFE) assessed weekly BDD symptoms and treatment received over 4 years for 166 broadly ascertained adults and adolescents with current BDD at intake. Kaplan-Meier life tables were constructed for time to remission and relapse. Full remission was defined as minimal or no BDD symptoms, and partial remission as less than full DSM-IV criteria, for at least 8 consecutive weeks. Full relapse and partial relapse were defined as meeting full BDD criteria for at least 2 consecutive weeks after attaining full or partial remission respectively. Cox proportional hazards regression examined predictors of remission and relapse.

RESULTS

Over 4 years, the cumulative probability was 0.20 for full remission and 0.55 for full or partial remission from BDD. A lower likelihood of full or partial remission was predicted by more severe BDD symptoms at intake, longer lifetime duration of BDD, and being an adult. Among partially or fully remitted subjects, the cumulative probability was 0.42 for subsequent full relapse and 0.63 for subsequent full or partial relapse. More severe BDD at intake and earlier age at BDD onset predicted full or partial relapse. Eighty-eight percent of subjects received mental health treatment during the follow-up period.

CONCLUSIONS

In this observational study, BDD tended to be chronic. Several intake variables predicted greater chronicity of BDD.

A comparison of insight in body dysmorphic disorder and obsessive-compulsive disorder

Insight/delusionality of beliefs is an important dimension of psychopathology across psychiatric disorders. This construct is of increasing interest in obsessive-compulsive and related disorders, including obsessive-compulsive disorder (OCD) and body dysmorphic disorder (BDD). Even though OCD and BDD are considered closely related, no prior study has compared these disorders across a range of categories of global insight (excellent, good, fair, poor, absent/delusional), and only one study has compared these disorders on individual components of insight. Using the reliable and valid Brown Assessment of Beliefs Scale (BABS), this study examined insight/delusionality of OCD- or BDD-related beliefs in 211 individuals with primary OCD versus 68 individuals with primary BDD. In both disorders, levels of insight spanned the full range, from excellent to absent (i.e., delusional beliefs). However, the distribution of BABS scores across insight categories differed significantly by disorder, with the majority of OCD subjects showing excellent or good insight, and the majority of BDD subjects showing poor or absent insight. Compared to OCD subjects, BDD subjects had significantly poorer insight both overall (total BABS score) and on all individual BABS items. BABS score was significantly correlated with BDD and OCD severity, but in regressions it accounted for only 21% of the variance in OCD and 28% in BDD. In summary, both global insight and its individual components are poorer in BDD than in OCD, which has implications for research and clinical care, as well as understanding of the relationship between these disorders. Disorder severity is associated with but not equivalent to insight/delusionality.

The relationship between body dysmorphic disorder behaviors and the acquired capability for suicide

In a sample of 200 individuals diagnosed with body dysmorphic disorder (BDD), we utilized the interpersonal-psychological theory for suicide as a framework to examine BDD behaviors that might be associated with suicide risk, insofar as they might increase the acquired capability for suicide. We predicted that physically painful BDD behaviors (e.g., cosmetic surgery, restrictive eating) would be associated with suicide attempts but not suicide-related ideation because these behaviors increase capability for, but not thoughts about, suicide. Our hypothesis was partially confirmed, as BDD-related restrictive food intake was associated with suicide attempts (but not suicide-related ideation) even after controlling for numerous covariates.

Olfactory reference syndrome: demographic and clinical features of imagined body odor

OBJECTIVE

Olfactory reference syndrome (ORS) - preoccupation with a false belief that one emits a foul or offensive body odor - has been described around the world for more than a century. However, only a few small studies have systematically assessed ORS's clinical features.

METHOD

Twenty patients with ORS were systematically assessed using semistructured measures.

RESULTS

Subjects' mean age was 33.4±14.1; 60% were female. Preoccupation most often focused on the mouth (75%), armpits (60%) and genitals (35%). Bad breath (75%) and sweat (65%) were the most common odor descriptions. Currently, 85% of subjects had delusional ORS beliefs, 77% had referential thinking and 85% reported actually smelling the odor. Ninety-five percent of subjects reported performing one or more ORS-related repetitive behaviors (e.g., excessive showering). Forty percent had been housebound for at least 1 week because of ORS symptoms, 68% had a history of suicidal ideation, 32% had attempted suicide and 53% had been psychiatrically hospitalized. Forty-four percent of subjects had sought nonpsychiatric medical, surgical or dental treatment for the perceived odor, and one third had received such treatment, which was ineffective in all cases.

CONCLUSION

ORS appears to be characterized by high morbidity and seeking of nonpsychiatric treatment.

A prospective pilot study of levetiracetam for body dysmorphic disorder

INTRODUCTION

Body dysmorphic disorder (BDD) is an often severe disorder, but few treatment studies have been conducted.

OBJECTIVE

This pilot study explored the efficacy and safety of the antiepileptic medication levetiracetam for BDD.

METHODS

Seventeen subjects with Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition BDD participated in a 12-week open-label levetiracetam trial. Subjects were assessed at regular intervals with standard measures.

RESULTS

In intent-to-treat analyses, scores on the Yale-Brown Obsessive Compulsive Scale Modified for BDD (BDD-YBOCS), the primary outcome measure, decreased from 32.5+/-4.7 at baseline to 21.5+/-11.0 at endpoint (P<.001). Approximately 60% (n=9) of subjects were responders (>30% decrease on the BDD-YBOCS). The mean time to response was 4.6+/-2.8 (range: 2-10) weeks. Scores also significantly improved on the Brown Assessment of Beliefs Scale, the Hamilton Rating Scale for Depression, the Global Assessment of Functioning Scale, and the Social and Occupational Functioning Assessment Scale. Scores did not significantly improve on the Quality of Life Enjoyment and Satisfaction Questionnaire, the Beck Anxiety Inventory, or the Social Phobia Inventory. The mean endpoint dose of levetiracetam was 2,044.1+/-1,065.2 (range: 250-3,000) mg/day, and it was relatively well-tolerated.

CONCLUSION

Randomized, double-blind placebo-controlled studies of levetiracetam for BDD are needed to confirm these preliminary findings.

Prevalence and clinical characteristics of body dysmorphic disorder in an adult inpatient setting

OBJECTIVE

Body dysmorphic disorder (BDD), a distressing or impairing preoccupation with an imagined or slight defect in appearance, is an often-severe, understudied disorder. We determined BDD's prevalence and clinical features on a general adult psychiatric inpatient unit. To our knowledge, only one previous prevalence study has been done in this setting.

METHOD

One hundred patients completed 3 self-report measures: the Body Dysmorphic Disorder Questionnaire (BDD-Q), Beck Anxiety Inventory (BAI) and Center for Epidemiologic Studies Depression Scale (CES-D). Those who screened positive for BDD were interviewed to confirm DSM-IV BDD and its clinical features. Charts were reviewed for demographic and clinical information.

RESULTS

BDD was diagnosed in 16.0% (95% CI=8.7-23.3%) (n=16) of patients. A high proportion of those with BDD reported that BDD symptoms contributed to suicidality. Patients revealed BDD symptoms to a mean of only 15.1%+/-33.7% lifetime mental health clinicians; only one (6.3%) reported symptoms to his current inpatient psychiatrist. Most did not disclose their symptoms due to embarrassment. Those with BDD were younger (P=.008) and had higher CES-D scores (P=.008). The two groups did not significantly differ on BAI score, demographic characteristics or discharge diagnoses.

CONCLUSIONS

BDD is relatively common but underdiagnosed in psychiatric inpatients and is associated with more severe depressive symptoms.

A comparison of quality of life and psychosocial functioning in obsessive-compulsive disorder and body dysmorphic disorder

BACKGROUND

Obsessive-compulsive disorder (OCD) and body dysmorphic disorder (BDD) are possibly related disorders characterized by poor functioning and quality of life. However, few studies have compared these disorders in these important domains.

METHODS

We compared functioning and quality of life in 210 OCD subjects, 45 BDD subjects, and 40 subjects with comorbid BDD+OCD using reliable and valid measures.

RESULTS

OCD and BDD subjects had very poor scores across all measures, with no statistically significant differences between the groups. However, comorbid BDD+OCD subjects had greater impairment than OCD subjects on 11 scales/subscales, which remained significant after controlling for OCD severity. Comorbid BDD+OCD subjects had greater impairment than BDD subjects on 2 scales/subscales, which were no longer significant after controlling for BDD severity, suggesting that BDD severity may have accounted for greater morbidity in the comorbid BDD+OCD group.

CONCLUSIONS

Functioning and quality of life were poor across all three groups, although individuals with comorbid BDD+OCD had greater impairment on a number of measures. It is important for clinicians to be aware that patients with these disorders--and, in particular, those with comorbid BDD and OCD--tend to have very poor functioning and quality of life across a broad range of domains.

Weight concerns in individuals with body dysmorphic disorder

OBJECTIVE

To determine the prevalence of weight concerns in individuals with BDD, and to examine similarities and differences between those with and those without weight concerns.

METHOD

We assessed 200 participants with BDD for clinically significant weight concerns and compared those with weight concerns (in addition to other body area concerns) to those without weight concerns on measures of BDD symptoms, other symptom severity, comorbidity, suicidality, functioning, and quality of life.

RESULTS

58 (29.0%) participants had weight concerns. Participants with weight concerns were younger, more likely to be female, and had more body areas of concern; a higher frequency of certain BDD behaviors, suicide attempts, and comorbidity; greater body image disturbance and depression; and poorer social functioning. The two groups were similar on other measures.

DISCUSSION

Weight concerns in BDD deserve further study, as they appear relatively common and are associated with greater symptom severity and psychopathology in several domains.

Clinical features and correlates of major depressive disorder in individuals with body dysmorphic disorder

BACKGROUND

Body dysmorphic disorder (BDD) and major depressive disorder (MDD) appear highly comorbid. However, MDD in individuals with BDD has received little investigation.

METHODS

The prevalence and characteristics of comorbid MDD were assessed in 178 BDD subjects. BDD subjects with current comorbid MDD (n=68) were compared to BDD subjects without current comorbid MDD (n=96) on demographic and clinical characteristics. Predictors of current MDD were determined using logistic regression.

RESULTS

74.2% of subjects had lifetime MDD, and 38.2% had current MDD. The melancholic subtype was most common, and a majority of depressed subjects had recurrent episodes. Mean onset of BDD occurred at a younger age than MDD. Subjects with current comorbid MDD had many similarities to those without MDD, although those with comorbid MDD had more severe BDD. Subjects with comorbid MDD were also more likely to have an anxiety or personality disorder, as well as a family history of MDD. They also had greater social anxiety, suicidality, and poorer functioning and quality of life. Current MDD was independently predicted by a personality disorder and more severe BDD.

LIMITATIONS

It is unclear how generalizable the results are to the community or to subjects ascertained for MDD who have comorbid BDD. The study lacked a comparison group such as MDD subjects without BDD.

CONCLUSIONS

MDD is common in individuals with BDD. Individuals with current MDD had greater morbidity in some clinically important domains, including suicidality, functioning, and quality of life. A personality disorder and more severe BDD independently predicted the presence of current MDD.

Obsessive-compulsive disorder versus body dysmorphic disorder: a comparison study of two possibly related disorders

The relationship between obsessive-compulsive disorder (OCD) and body dysmorphic disorder (BDD) is unclear. BDD has been proposed to be an OCD-spectrum disorder or even a type of OCD. However, few studies have directly compared these disorders' clinical features. We compared characteristics of subjects with OCD (n=210), BDD (n=45), and comorbid BDD/OCD (n=40). OCD and BDD did not significantly differ in terms of demographic features, age of OCD or BDD onset, illness duration, and many other variables. However, subjects with BDD had significantly poorer insight than those with OCD and were more likely to be delusional. Subjects with BDD were also significantly more likely than those with OCD to have lifetime suicidal ideation, as well as lifetime major depressive disorder and a lifetime substance use disorder. The comorbid BDD/OCD group evidenced greater morbidity than subjects with OCD or BDD in a number of domains, but differences between the comorbid BDD/OCD group and the BDD group were no longer significant after controlling for BDD severity. However, differences between the comorbid BDD/OCD group and the OCD group remained significant after controlling for OCD severity. In summary, OCD and BDD did not significantly differ on many variables but did have some clinically important differences. These findings have implications for clinicians and for the classification of these disorders.

Childhood abuse and neglect in body dysmorphic disorder

OBJECTIVE

No published studies have examined childhood abuse and neglect in body dysmorphic disorder (BDD). This study examined the prevalence and clinical correlates of abuse and neglect in individuals with this disorder.

METHODS

Seventy-five subjects (69.3% female, mean age=35.4+/-12.0) with DSM-IV BDD completed the Childhood Trauma Questionnaire and were interviewed with other reliable and valid measures.

RESULTS

Of these subjects, 78.7% reported a history of childhood maltreatment: emotional neglect (68.0%), emotional abuse (56.0%), physical abuse (34.7%), physical neglect (33.3%), and sexual abuse (28.0%). Forty percent of subjects reported severe maltreatment. Among females (n=52), severity of reported abuse and neglect were .32-.57 standard deviation units higher than norms for a health maintenance organization (HMO) sample of women. Severity of sexual abuse was the only type of maltreatment significantly associated with current BDD severity (r=.23, p=.047). However, severity of sexual abuse did not predict current BDD severity in a simultaneous multiple regression analysis with age and current treatment status. There were other significant associations with childhood maltreatment: history of attempted suicide was related to emotional (p=.004), physical (p=.014), and sexual abuse (p=.038). Childhood emotional abuse was associated with a lifetime substance use disorder (r=.26, p=.02), and physical abuse was negatively associated with a lifetime mood disorder (r=-.37, p=.001).

CONCLUSIONS

A high proportion of individuals with BDD reported childhood abuse and neglect. Certain types of abuse and neglect appear modestly associated with BDD symptom severity and with gender, suicidality, and certain disorders.

Pharmacotherapy for body dysmorphic disorder: treatment received and illness severity

BACKGROUND

Research on pharmacotherapy received by individuals with body dysmorphic disorder (BDD), a relatively common and impairing disorder, is very limited.

METHODS

We examined past and current pharmacotherapy received by 151 individuals with BDD who were recruited from diverse sources.

RESULTS

72.9% of subjects had received psychotropic medication. The most common type ever received was an SRI (65.6%), followed by non-SRI antidepressants (41.1%) and benzodiazepines (27.2%). Subjects with greater lifetime impairment due to BDD were more likely to have received pharmacotherapy, and subjects with lifetime OCD or greater lifetime impairment due to BDD were more likely to have received an SRI specifically. Subjects revealed their BDD symptoms to only 41.0% of pharmacotherapists. Only 12.9% of SRI trials were considered optimal for BDD, and an additional 21.5% were considered minimally adequate. SRI trials that were considered optimal or at least minimally adequate for BDD were associated with greater improvement in BDD and less severe current BDD symptoms than non-optimal or inadequate SRI trials.

CONCLUSIONS

A high proportion of individuals with BDD receive pharmacotherapy, primarily SRIs, although most SRI trials appear inadequate for BDD. SRI treatment that was considered adequate was associated with greater improvement in BDD and less severe BDD symptoms.

Suicidality in body dysmorphic disorder: a prospective study

OBJECTIVE

Cross-sectional/retrospective data have indicated that individuals with body dysmorphic disorder (BDD) have high rates of suicidal ideation and attempts. However, no study, to the authors' knowledge, has prospectively examined suicidality in BDD.

METHOD

In the first prospective study of BDD's course, the authors examined suicidality in 185 subjects for up to 4 years.

RESULTS

Suicidal ideation was reported by a mean of 57.8% of the subjects per year, and a mean of 2.6% attempted suicide per year. Two subjects (0.3% per year) completed suicide.

CONCLUSIONS

Individuals with BDD have high rates of suicidal ideation and attempts. The completed suicide rate is preliminary but suggests that the rate of completed suicide in BDD is markedly high.

Suicidality in body dysmorphic disorder: a prospective study

OBJECTIVE

Cross-sectional/retrospective data have indicated that individuals with body dysmorphic disorder (BDD) have high rates of suicidal ideation and attempts. However, no study, to the authors' knowledge, has prospectively examined suicidality in BDD.

METHOD

In the first prospective study of BDD's course, the authors examined suicidality in 185 subjects for up to 4 years.

RESULTS

Suicidal ideation was reported by a mean of 57.8% of the subjects per year, and a mean of 2.6% attempted suicide per year. Two subjects (0.3% per year) completed suicide.

CONCLUSIONS

Individuals with BDD have high rates of suicidal ideation and attempts. The completed suicide rate is preliminary but suggests that the rate of completed suicide in BDD is markedly high.

A 12-month follow-up study of the course of body dysmorphic disorder

OBJECTIVE

This study investigated the course of body dysmorphic disorder (BDD), a relatively common and severe disorder, in the first prospective follow-up study, to the authors' knowledge.

METHOD

In this study, the authors obtained data with the Longitudinal Interval Follow-Up Evaluation on weekly BDD symptom status and treatment received over 1 year for 183 broadly ascertained subjects. Probabilities of full remission, partial remission, and relapse during this year were examined. Full remission was defined as minimal or no BDD symptoms and partial remission, as meeting less than full DSM-IV criteria for at least 8 consecutive weeks. Relapse was defined as meeting full BDD criteria for at least 2 consecutive weeks after attaining partial or full remission from BDD.

RESULTS

Over 1 year, the probability of full remission from BDD was only 0.09, and the probability of partial remission was 0.21. Although 84.2% of the subjects received mental health treatment during the 1-year period, mean BDD severity scores during the year reflected full DSM-IV criteria for BDD, and the mean proportion of time that the subjects met full BDD criteria was 80%. Gender and ethnicity did not significantly predict remission from BDD. Among the subjects whose BDD symptoms partially or fully remitted, the probability of relapse was 0.15.

CONCLUSIONS

These findings indicate that BDD tends to be chronic. Remission probabilities were lower than reported for mood disorders, most anxiety disorders, and personality disorders in studies with similar methods.

Clinical features of body dysmorphic disorder in adolescents and adults

Body dysmorphic disorder (BDD) usually begins during adolescence, but its clinical features have received little investigation in this age group. Two hundred individuals with BDD (36 adolescents; 164 adults) completed interviewer-administered and self-report measures. Adolescents were preoccupied with numerous aspects of their appearance, most often their skin, hair, and stomach. Among the adolescents, 94.3% reported moderate, severe, or extreme distress due to BDD, 80.6% had a history of suicidal ideation, and 44.4% had attempted suicide. Adolescents experienced high rates and levels of impairment in school, work, and other aspects of psychosocial functioning. Adolescents and adults were comparable on most variables, although adolescents had significantly more delusional BDD beliefs and a higher lifetime rate of suicide attempts. Thus, adolescents with BDD have high levels of distress and rates of functional impairment, suicidal ideation, and suicide attempts. BDD's clinical features in adolescents appear largely similar to those in adults.

Delusional versus nondelusional body dysmorphic disorder: clinical features and course of illness

DSM-IV's classification of body dysmorphic disorder (BDD) is controversial. Whereas BDD is classified as a somatoform disorder, its delusional variant is classified as a psychotic disorder. However, the relationship between these BDD variants has received little investigation. In this study, we compared BDD's delusional and nondelusional variants in 191 subjects using reliable and valid measures that assessed a variety of domains. Subjects with delusional BDD were similar to those with nondelusional BDD in terms of most variables, including most demographic features, BDD characteristics, most measures of functional impairment and quality of life, comorbidity, and family history. Delusional and nondelusional subjects also had a similar probability of remitting from BDD over 1 year of prospective follow-up. However, delusional subjects had significantly lower educational attainment, were more likely to have attempted suicide, had poorer social functioning on several measures, were more likely to have drug abuse or dependence, were less likely to currently be receiving mental health treatment, and had more severe BDD symptoms. However, when controlling for BDD symptom severity, the two groups differed only in terms of educational attainment. These findings indicate that BDD's delusional and nondelusional forms have many more similarities than differences, although on several measures delusional subjects evidenced greater morbidity, which appeared accounted for by their more severe BDD symptoms. Thus, these findings offer some support for the hypothesis that these two BDD variants may constitute the same disorder. Additional studies are needed to examine this issue, which may have relevance for other disorders with both delusional and nondelusional variants in DSM.

Gender similarities and differences in 200 individuals with body dysmorphic disorder

BACKGROUND

Gender is a critically important moderator of psychopathology. However, gender similarities and differences in body dysmorphic disorder (BDD) have received scant investigation. In this study, we examined gender similarities and differences in the broadest sample in which this topic has been examined.

METHODS

Two hundred subjects with BDD recruited from diverse sources were assessed with a variety of standard measures.

RESULTS

There were more similarities than differences between men and women, but many gender differences were found. The men were significantly older and more likely to be single and living alone. Men were more likely to obsess about their genitals, body build, and thinning hair/balding; excessively lift weights; and have a substance use disorder. In contrast, women were more likely to obsess about their skin, stomach, weight, breasts/chest, buttocks, thighs, legs, hips, toes, and excessive body/facial hair, and they were excessively concerned with more body areas. Women also performed more repetitive and safety behaviors, and were more likely to camouflage and use certain camouflaging techniques, check mirrors, change their clothes, pick their skin, and have an eating disorder. Women also had earlier onset of subclinical BDD symptoms and more severe BDD as assessed by the Body Dysmorphic Disorder Examination. However, men had more severe BDD as assessed by the Psychiatric Status Rating Scale for Body Dysmorphic Disorder, and they had poorer Global Assessment of Functioning Scale scores, were less likely to be working because of psychopathology, and were more likely to be receiving disability, including disability for BDD.

CONCLUSIONS

The clinical features of BDD in men and women have many similarities but also some interesting and important differences. These findings have implications for the detection and treatment of BDD.

Nonpsychiatric medical treatment of body dysmorphic disorder

Many individuals with body dysmorphic disorder seek nonpsychiatric medical and surgical treatment to improve perceived defects in their physical appearance. However, the types of treatments sought and received, as well as the treatment outcome, have received little investigation. This study describes the frequency, types, and outcomes of treatments sought and received by 200 individuals with body dysmorphic disorder. Treatment was sought by 71.0% and received by 64.0%. Dermatological treatment was most frequently sought and received (most often, topical acne agents), followed by surgery (most often, rhinoplasty). Twelve percent of the subjects received isotretinoin. Such treatment rarely improved body dysmorphic disorder. Thus, nonpsychiatric medical treatments do not appear effective in its treatment.

Comorbidity of body dysmorphic disorder and eating disorders: severity of psychopathology and body image disturbance

OBJECTIVE

The current study examined comorbidity and clinical correlates of eating disorders in a large sample of individuals with body dysmorphic disorder (BDD).

METHOD

Two hundred individuals with DSM-IV (4th ed. of the Diagnostic and Statistical Manual of Mental Disorders. Washington, DC: American Psychiatric Association; 1994) BDD completed reliable interviewer-administered and self-report measures, including diagnostic assessments and measures of body image, symptom severity, delusionality, psychosocial functioning, quality of life (QOL), and history of psychiatric treatment.

RESULTS

A total of 32.5% of BDD subjects had a comorbid lifetime eating disorder: 9.0% had anorexia nervosa, 6.5% had bulimia nervosa, and 17.5% had an eating disorder not otherwise specified. Comparisons of subjects with a comorbid lifetime eating disorder (n = 65) and subjects without an eating disorder (n = 135) indicated that the comorbid group was more likely to be female, less likely to be African American, had more comorbidity, and had significantly greater body image disturbance and dissatisfaction. There were no significant group differences in BDD symptom severity, degree of delusionality, or suicidal ideation or attempts. Functioning and QOL were notably poor in both groups, with no significant between-group differences. However, a higher proportion of the comorbid eating disorder group had been hospitalized for psychiatric problems. This group had also received a greater number of psychotherapy sessions and psychotropic medications.

CONCLUSION

Eating disorders appear relatively common in individuals with BDD. BDD subjects with a comorbid eating disorder differed on several demographic variables, had greater comorbidity and body image disturbance, and had received more mental health treatment than subjects without a comorbid eating disorder. These findings have important implications for the assessment and treatment of these comorbid body image disorders.

Pathological skin picking in individuals with body dysmorphic disorder

OBJECTIVE

The objective of this study was to examine the prevalence and clinical correlates of pathological skin picking (PSP) in a large sample of individuals with body dysmorphic disorder (BDD).

METHOD

One hundred seventy-six individuals with BDD (71.0% women; mean age, 32.5+/-12.3 years) were assessed with respect to comorbidity, BDD severity, delusionality (insight), quality of life and social/occupational functioning, using reliable and valid measures. All variables were compared in BDD subjects with and without lifetime PSP.

RESULTS

About 44.9% of subjects reported lifetime PSP, and 36.9% reported current PSP secondary to BDD. BDD subjects with PSP were more likely to be female, to have skin preoccupations, to have comorbid trichotillomania or a personality disorder, to camouflage with makeup and to seek and receive nonpsychiatric (e.g., dermatological) treatment for their skin preoccupations.

CONCLUSION

There is a high prevalence of PSP among individuals with BDD, and clinicians should be aware of the clinical correlates of this problematic behavior.

Social functioning in body dysmorphic disorder: assessment considerations

Individuals with body dysmorphic disorder (BDD) have markedly poor social functioning; however, previous reports may underestimate impairment. Scoring on certain functioning measures such as the Social Adjustment Scale-Self Report (SAS-SR) potentially excludes more severely ill individuals from some domains, thereby possibly underestimating functional impairment. To explore this issue, 73 individuals with BDD who reported having no primary relationship (and were therefore excluded from scoring on the SAS-SR Primary Relationship domain) were compared to 58 individuals with BDD who had a primary relationship. Subjects without a primary relationship had significantly poorer global social adjustment on several measures. They also had poorer scores on the Global Assessment of Functioning Scale and greater severity of BDD and depressive symptoms at a trend level. These findings suggest that the SAS-SR may underestimate social impairment. This underestimation may pertain to other domains of functioning, other disorders, and certain other functioning and quality of life measures.

Tanning in body dysmorphic disorder

Tanning in body dysmorphic disorder (BDD) has not previously been studied. In this study, 200 subjects with BDD were evaluated with measures to examine the prevalence of BDD-related tanning--i.e., darkening one's skin color by direct exposure to sunlight or artificial light which is motivated by a desire to improve a perceived appearance defect (i.e., a BDD concern). We also examined clinical characteristics of individuals who engaged in BDD-related tanning. 25% (95% CI, 19.0%-31.0%) of subjects reported BDD-related tanning. Among tanners, the skin was the most common body area of concern (84.0%). All tanners experienced functional impairment due to BDD, 26% had attempted suicide, and quality of life was markedly poor. 52% of tanners had received dermatologic treatment, which was usually ineffective for BDD symptoms. Tanners were more likely than non-tanners to compulsively pick their skin. In conclusion, tanning--a behavior with well-known health risks--is a relatively frequent BDD-related behavior.

Body dysmorphic disorder and social phobia: cross-sectional and prospective data

Much attention has been paid to the relationship between body dysmorphic disorder (BDD) and obsessive-compulsive disorder (OCD). However, to our knowledge, no published study has focused directly on the relationship between BDD and social phobia (SP). This is striking given similar clinical features of the two disorders, data showing elevated comorbidity between them, and Eastern conceptualizations of BDD as a form of SP. In this study, 39.3% of 178 individuals with current BDD had comorbid lifetime SP, and 34.3% had current SP. SP onset was typically before BDD. Individuals with BDD, with and without lifetime SP, were similar on many general characteristics (e.g., age of BDD onset, gender distribution, BDD severity, overall functional disability). However, subjects with BDD+SP were significantly less likely to be employed, were more likely to report lifetime suicidal ideation, and had poorer global social adjustment on one of two measures. Both BDD and SP were associated with elevated social anxiety; subjects with BDD+SP experienced additional social anxiety that appeared independent of BDD symptoms. Examining 1-year prospective data available for 161 subjects, BDD+SP subjects were somewhat less likely to experience remission (partial or full) of their BDD symptoms over 1-year follow-up, although this difference was not statistically significant (hazard ratio = .64, P = .18). In summary, these findings, including elevated rates of SP in patients with BDD, highlight a need for additional research on the relationship between BDD and SP.

Clinical features of muscle dysmorphia among males with body dysmorphic disorder

Muscle dysmorphia - a pathological preoccupation with muscularity - appears to be a form of body dysmorphic disorder (BDD) with a focus on muscularity. However, little is known about muscle dysmorphia in men with BDD, and no study has compared men with BDD who do and do not report muscle dysmorphia. To explore this issue, we reviewed the histories of 63 men with BDD; we compared those rated as having a history of muscle dysmorphia with those who had BDD but not muscle dysmorphia in several domains. The 14 men with muscle dysmorphia resembled the 49 comparison men in demographic features, BDD severity, delusionality, and number of non-muscle-related body parts of concern. However, those with muscle dysmorphia were more likely to have attempted suicide, had poorer quality of life, and had a higher frequency of any substance use disorder and anabolic steroid abuse. Thus, muscle dysmorphia was associated with greater psychopathology.

Predictors of remission from body dysmorphic disorder: a prospective study

In the first naturalistic, prospective study of the course of body dysmorphic disorder (BDD), we examined predictors of remission in 161 subjects over 1 year of follow-up. Data were obtained on clinical characteristics at the intake interview and weekly BDD symptom severity over 1 year using the Longitudinal Interval Follow-Up Evaluation. More severe BDD at intake, longer BDD duration, and the presence of a comorbid personality disorder predicted a lower likelihood of partial or full remission from BDD. BDD remission was not predicted by gender; race/ethnicity; socioeconomic status; being an adult versus an adolescent; age of BDD onset; delusionality of BDD symptoms; or the presence at intake of major depression, a substance use disorder, social phobia, obsessive compulsive disorder, or an eating disorder. Receipt of mental health treatment or nonmental health treatment (e.g., surgery, dermatologic treatment) during the follow-up year also did not predict remission from BDD.

Demographic characteristics, phenomenology, comorbidity, and family history in 200 individuals with body dysmorphic disorder

The authors examined characteristics of body dysmorphic disorder in the largest sample for which a wide range of clinical features has been reported. The authors also compared psychiatrically treated and untreated subjects. Body dysmorphic disorder usually began during adolescence, involved numerous body areas and behaviors, and was characterized by poor insight, high comorbidity rates, and high rates of functional impairment, suicidal ideation, and suicide attempts. There were far more similarities than differences between the currently treated and untreated subjects, although the treated subjects displayed better insight and had more comorbidity.

Suicidal ideation and suicide attempts in body dysmorphic disorder

OBJECTIVE

Because suicidality in body dys-morphic disorder (BDD) has received little investigation, this study examined rates, correlates, predictors, and other aspects of suicidal ideation and suicide attempts in this disorder.

METHOD

From January 2001 to June 2003, 200 subjects with DSM-IV BDD recruited from diverse sources were assessed with standard measures.

RESULTS

Subjects had high rates of lifetime suicidal ideation (78.0%) and suicide attempts (27.5%). Body dysmorphic disorder was the primary reason for suicidal ideation in 70.5% of those with a history of ideation and nearly half of subjects with a past attempt. Suicidal subjects often did not reveal their BDD symptoms to their clinician. In univariate analyses, both suicidal ideation and suicide attempts were associated with lifetime functional impairment due to BDD (p < .001), current functional impairment (p < .001 to < .05), lifetime bipolar disorder (p < .05), any personality disorder (p < .05 to .001), and comorbid borderline personality disorder (p < .01 to < .001). A history of suicidal ideation (but not suicide attempts) was additionally associated with comorbid lifetime major depression (p = .001). A history of suicide attempts (but not suicidal ideation) was additionally associated with delusional appearance beliefs (p = .01) and lifetime posttraumatic stress disorder (PTSD), an eating disorder, or a substance use disorder (p < .001 to < .05). In logistic regression analyses, suicidal ideation was significantly predicted by comorbid major depression (p = .010) and greater lifetime impairment due to BDD (p = .003); suicide attempts were significantly predicted by PTSD (p = .011), a substance use disorder (p = .011), and greater lifetime impairment due to BDD (p = .005).

CONCLUSION

Individuals with BDD have high rates of suicidal ideation and suicide attempts. Lifetime impairment due to BDD and certain comorbid disorders are associated with suicidality.

Substance use disorders in individuals with body dysmorphic disorder

BACKGROUND

Little is known about substance use disorders (SUDs) in individuals with body dysmorphic disorder (BDD). Although studies have examined SUD comorbidity in BDD, no previous studies have examined clinical correlates of SUD comorbidity.

METHOD

We examined rates and clinical correlates of comorbid SUDs in 176 consecutive subjects with DSM-IV BDD (71% female; mean +/- SD age = 32.5 +/- 12.3 years). Comorbidity data were obtained with the Structured Clinical Interview for DSM-IV. BDD severity was assessed with the Yale-Brown Obsessive Compulsive Scale Modified for BDD, and delusionality (insight) was assessed with the Brown Assessment of Beliefs Scale. Quality of life and social/occupational functioning were examined using the Social Adjustment Scale, Quality of Life Enjoyment and Satisfaction Questionnaire, Medical Outcomes Study 36-Item Short-Form Health Survey, and Range of Impaired Functioning Tool. All variables were compared in BDD subjects with and without lifetime and current SUDs. Data were collected from January 2001 to June 2003.

RESULTS

48.9% of BDD subjects (N = 86) had a lifetime SUD, 29.5% had lifetime substance abuse, and 35.8% had lifetime substance dependence (most commonly, alcohol dependence [29.0%]). 17% (N = 30) had current substance abuse or dependence (9.1% reported current substance abuse, and 9.7% reported current dependence). 68% of subjects with a lifetime SUD reported that BDD contributed to their SUD. There were far more similarities than differences between subjects with a comorbid SUD and those without an SUD, although those with a lifetime SUD had a significantly higher rate of suicide attempts (p = .004).

CONCLUSION

These preliminary results suggest that SUDs are very common in individuals with BDD. Subjects with and without a comorbid SUD were similar in most domains that were examined.

Psychosocial functioning and quality of life in body dysmorphic disorder

Psychosocial functioning and quality of life in body dysmorphic disorder (BDD) have received only limited investigation. We examined these domains in 176 subjects with current Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), BDD using reliable measures, several of which have not been used previously in BDD studies. Scores were compared to published norms. On the Medical Outcomes Study 36-Item Short-Form Health Survey, mental health-related quality of life scores for BDD subjects were approximately 1.8 SD units poorer than US population norms and 0.4 SD units poorer than norms for depression. On the Quality of Life Enjoyment and Satisfaction Questionnaire Short Form, BDD subjects had a mean converted score of 49.9% +/- 16.4%, which was 2.1 SD units poorer than the normative community sample score of 78.1% +/- 13.7%. On the Social Adjustment Scale-Self-Report, BDD subjects had a mean Overall Adjustment total score of 2.37 +/- 0.52, which was 2.4 SD units poorer than the published norm of 1.59 +/- 0.33. Scores on the Range of Impaired Functioning Tool reflected functional impairment in all domains. More severe BDD symptoms were significantly associated with poorer functioning and quality of life on all measures. On all but one measure, functioning and quality of life for subjects who were not currently receiving mental health treatment did not significantly differ from those who were receiving treatment. These findings indicate that individuals with BDD, regardless of treatment status, have markedly poor functioning and quality of life. In addition, they suggest that treatment should aim at improving functioning and quality of life in addition to relieving symptoms.

Environmental Support for Older and Younger Pilots' Comprehension of Air Traffic Control Information

We investigated whether expertise mitigates age differences on pilot communication tasks when experts rely on environmental support. Pilots and nonpilots listened to air traffic control messages describing a route through an airspace, during which they referred to a chart of the airspace. The routes were high (waypoint routes anchored to navigational reference points on the chart) or low (vector routes that were not) in contextual support. Participants read back messages and answered questions about aircraft position (which required integration of message and chart information) or altitude (which did not). Pilots more accurately answered questions. The expertise advantage for position, but not altitude, questions was greater for waypoint routes, showing differential use of environmental support by experts. Age did not moderate these effects.

Delusionality and response to open-label fluvoxamine in body dysmorphic disorder

BACKGROUND

Available data suggest that the delusional variant of body dysmorphic disorder (BDD), a type of delusional disorder, may respond to serotonin reuptake inhibitors (SRIs) and that delusionality (lack of insight) in BDD may improve with SRI treatment. However, this research has been hampered by the lack of a reliable and valid scale to assess delusionality.

METHOD

Thirty subjects (21 women, 9 men; mean age = 33.3 +/- 9.0 years) with DSM-IV BDD were prospectively treated with open-label fluvoxamine for 16 weeks. Subjects were assessed at regular intervals with the Brown Assessment of Beliefs Scale (BABS), the Yale-Brown Obsessive Compulsive Scale Modified for BDD (BDD-YBOCS; a measure of BDD severity), and other instruments. The BABS is a reliable and valid 7-item, semistructured, clinician-administered scale that assesses current delusionality.

RESULTS

In this prospective, open-label study, 63% of BDD subjects responded to fluvoxamine. Delusional and nondelusional subjects had similar improvement in BDD symptoms. In addition, insight significantly improved in both delusional and nondelusional subjects. Baseline BABS scores did not contribute significantly to endpoint BDD-YBOCS scores in a regression analysis.

CONCLUSION

Degree of delusionality did not predict fluvoxamine response, and delusionality significantly improved. These findings are preliminary and require confirmation in controlled trials. The implications of these findings for other types of delusions requires investigation.