Psychometric evaluation of the appearance anxiety inventory in adolescents with body dysmorphic disorder.

The Appearance Anxiety Inventory (AAI) is a self-report measure assessing the typical cognitions and behaviours of body dysmorphic disorder (BDD). Despite its use in research and clinical settings, its psychometric properties have not been evaluated in young people with BDD. We examined the factor structure, reliability, validity, and sensitivity to change of the AAI in 182 youths with BDD (82.9% girls; Mage = 15.56, SD = 1.37) consecutively referred to two specialist outpatient clinics in Stockholm, Sweden (n = 97) and London, England (n = 85). An exploratory factor analysis identified three factors, namely "threat monitoring", "camouflaging", and "avoidance", explaining 48.15% of the variance. The scale showed good internal consistency (McDonalds omega = 0.83) and adequate convergent validity with the Yale-Brown Obsessive-Compulsive Scale Modified for Body Dysmorphic Disorder for Adolescents (BDD-YBOCS-A; rs = 0.42) and the Clinical Global Impression-Severity Scale (rs = 0.32). Sensitivity to change was adequate, with AAI total scores and individual factor scores significantly decreasing over time in the subgroup of participants receiving multimodal treatment for BDD (n = 79). Change of AAI scores over treatment showed a positive statistically significant moderate-to-good correlation (r = 0.55) with changes in BDD symptom severity, measured by the BDD-YBOCS-A. The study provides empirical support for the use of the AAI in young people with BDD in clinical settings.

Adverse Childhood Experiences Among Adolescents With Body Dysmorphic Disorder: Frequency and Clinical Correlates.

Increasing empirical attention has been given to the role of adverse childhood experiences (ACEs) in the development and maintenance of body dysmorphic disorder (BDD). Yet, current research has predominantly focused on adult and nonclinical BDD samples, and little is known about relevance of ACEs in adolescent BDD. The present study examined (a) the frequency of ACEs in adolescents with a primary diagnosis of BDD (n = 50) versus obsessive compulsive disorder (OCD) (n = 50) and (b) the clinical profile of ACE-exposed youth with BDD. ACEs were ascertained through a systematic search of electronic patient records, as well as through a parent- and self-report screening item for exposure to traumatic events. Results showed higher rate of peer victimisation (74% vs. 38%) and child maltreatment (44% vs. 24%) among BDD versus OCD youths; sexual abuse was the most common type of child maltreatment documented in the BDD group (28%) according to patient records. Parent-reported exposure to traumatic events was also significantly higher in the BDD than the OCD group (40% vs. 18%, respectively). Clinical presentation and treatment outcomes did not differ between those with versus without a history of ACEs. The current study is the first to demonstrate that a range of ACEs are common in adolescent BDD. Our findings highlight the importance of screening for these experiences. Although further research is needed, our findings also indicate that adolescents with BDD who have a history of ACEs are broadly similar in their clinical presentation to those without, and benefit from BDD-focused treatment.

Psychometric Evaluation of the Yale-Brown Obsessive-Compulsive Scale Modified for Body Dysmorphic Disorder for Adolescents (BDD-YBOCS-A).

The Yale-Brown Obsessive-Compulsive Scale Modified for Body Dysmorphic Disorder for Adolescents (BDD-YBOCS-A) is a clinician-rated measure of BDD symptom severity in youth. Despite widespread use in both research and clinical practice, its psychometric properties have not been formally evaluated. The current study examined the factor structure, reliability, validity, and sensitivity to change of the BDD-YBOCS-A in 251 youths with BDD attending two specialist clinics. A principal component analysis identified two factors, explaining 56% of the variance. The scale showed good internal consistency (Cronbach's alpha = 0.87) and adequate convergent and divergent validity. In a subgroup of participants receiving BDD treatment (n = 175), BDD-YBOCS-A scores significantly decreased over time, demonstrating sensitivity to change. BDD-YBOCS-A change scores over treatment were highly correlated with severity changes measured by the Clinical Global Impression - Severity scale (r = .84). The study provides empirical support for the use of the BDD-YBOCS-A in children and adolescents with BDD.

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.

Empirically defining treatment response and remission in body dysmorphic disorder.

BACKGROUND: The number of clinical trials in body dysmorphic disorder (BDD) has steadily increased in recent years. As the number of studies grows, it is important to define the most empirically useful definitions for response and remission in order to enhance field-wide consistency and comparisons of treatment outcomes across studies. In this study, we aim to operationally define treatment response and remission in BDD. METHOD: We pooled data from three randomized controlled trials of cognitive-behavior therapy (CBT) for BDD (combined n = 153) conducted at four academic sites in Sweden, the USA, and England. Using signal detection methods, we examined the Yale-Brown Obsessive Compulsive Scale modified for BDD (BDD-YBOCS) score that most reliably identified patients who responded to CBT and those who achieved remission from BDD symptoms at the end of treatment. RESULTS: A BDD-YBOCS reduction ⩾30% was most predictive of treatment response as defined by the Clinical Global Impression (CGI) - Improvement scale (sensitivity 0.89, specificity 0.91, 91% correctly classified). At post-treatment, a BDD-YBOCS score ⩽16 was the best predictor of full or partial symptom remission (sensitivity 0.85, specificity 0.99, 97% correctly classified), defined by the CGI - Severity scale. CONCLUSION: Based on these results, we propose conceptual and operational definitions of response and full or partial remission in BDD. A consensus regarding these constructs will improve the interpretation and comparison of future clinical trials, as well as improve communication among researchers, clinicians, and patients. Further research is needed, especially regarding definitions of full remission, recovery, and relapse.

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

BACKGROUND: Body dysmorphic disorder (BDD) usually begins during adolescence but little is known about the prevalence, etiology, and patterns of comorbidity in this age group. We investigated the prevalence of BDD symptoms in adolescents and young adults. We also report on the relative importance of genetic and environmental influences on BDD symptoms, and the risk for co-existing psychopathology. METHODS: Prevalence of BDD symptoms was determined by a validated cut-off on the Dysmorphic Concerns Questionnaire (DCQ) in three population-based twin cohorts at ages 15 (n = 6968), 18 (n = 3738), and 20-28 (n = 4671). Heritability analysis was performed using univariate model-fitting for the DCQ. The risk for co-existing psychopathology was expressed as odds ratios (OR). RESULTS: The prevalence of clinically significant BDD symptoms was estimated to be between 1 and 2% in the different cohorts, with a significantly higher prevalence in females (1.3-3.3%) than in males (0.2-0.6%). The heritability of body dysmorphic concerns was estimated to be 49% (95% CI 38-54%) at age 15, 39% (95% CI 30-46) at age 18, and 37% (95% CI 29-42) at ages 20-28, with the remaining variance being due to non-shared environment. ORs for co-existing neuropsychiatric and alcohol-related problems ranged from 2.3 to 13.2. CONCLUSIONS: Clinically significant BDD symptoms are relatively common in adolescence and young adulthood, particularly in females. The low occurrence of BDD symptoms in adolescent boys may indicate sex differences in age of onset and/or etiological mechanisms. BDD symptoms are moderately heritable in young people and associated with an increased risk for co-existing neuropsychiatric and alcohol-related problems.

Understanding the covariation of tics, attention-deficit/hyperactivity, and obsessive-compulsive symptoms: A population-based adult twin study.

Chronic tic disorders (TD), attention-deficit/hyperactivity-disorder (ADHD), and obsessive-compulsive disorder (OCD) frequently co-occur in clinical and epidemiological samples. Family studies have found evidence of shared familial transmission between TD and OCD, whereas the familial association between these disorders and ADHD is less clear. This study aimed to investigate to what extent liability of tics, attention-deficit/hyperactivity, and obsessive-compulsive symptoms is caused by shared or distinct genetic or environmental influences, in a large population-representative sample of Swedish adult twins (n = 21,911). Tics, attention-deficit/hyperactivity, and obsessive-compulsive symptoms showed modest, but significant covariation. Model fitting suggested a latent liability factor underlying the three phenotypes. This common factor was relatively heritable, and explained significantly less of the variance of attention-deficit/hyperactivity symptom liability. The majority of genetic variance was specific rather than shared. The greatest proportion of total variance in liability of tics, attention-deficit/hyperactivity, and obsessive-compulsive symptoms was attributed to specific non-shared environmental influences. Our findings suggest that the co-occurrence of tics and obsessive-compulsive symptoms, and to a lesser extent attention-deficit/hyperactivity symptoms, can be partly explained by shared etiological influences. However, these phenotypes do not appear to be alternative expressions of the same underlying genetic liability. Further research examining sub-dimensions of these phenotypes may serve to further clarify the association between these disorders and identify more genetically homogenous symptom subtypes. © 2016 Wiley Periodicals, Inc.

EFFECTS OF HOMEWORK COMPLIANCE ON COGNITIVE-BEHAVIORAL THERAPY WITH D-CYCLOSERINE AUGMENTATION FOR CHILDREN WITH OBSESSIVE COMPULSIVE DISORDER.

BACKGROUND: The present study examined the effects of homework compliance on outcome from cognitive behavioral therapy (CBT) for children with obsessive-compulsive disorder (OCD) and the extent to which these effects differ as a function of augmentation of CBT with D-cycloserine (DCS). METHODS: Twenty-seven youth with OCD were randomized to either 50 mg DCS or placebo (PBO) administered immediately after each of 10 CBT sessions, primarily consisting of exposure and ritual prevention (ERP). Independent evaluators assessed OCD severity using the Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) at the start of each session. Compliance with between-session ERP assignments was also assessed at the start of each session using the Patient ERP Adherence Scale (PEAS). RESULTS: Greater homework compliance between the previous session and the current session was related to lower CY-BOCS at the current session. However, the relation between homework compliance and CY-BOCS varied by treatment condition. Higher homework compliance was related to lower CY-BOCS for participants in the DCS condition, but not for participants in the PBO condition. Furthermore, participants receiving DCS were estimated to have significantly lower CY-BOCS than those given PBO among those with the highest levels of homework compliance. CONCLUSIONS: DCS may more effectively facilitate the effects of CBT for youth with OCD when patients are compliant with prescribed homework. Theoretical and clinical implications are discussed.

Cognitive-behavioural therapy with post-session D-cycloserine augmentation for paediatric obsessive-compulsive disorder: pilot randomised controlled trial.

A partial N-methyl-D-aspartate agonist, D-cycloserine, enhances fear extinction when given before or shortly after exposure to feared stimuli in animals. In this pilot double-blind placebo-controlled trial (trial number: ISRCTN70977225), 27 youth with obsessive-compulsive disorder were randomised to either 50 mg D-cycloserine or placebo administered immediately after each of ten cognitive-behavioural therapy (CBT) sessions, primarily consisting of exposure and ritual prevention. Both groups improved significantly and maintained their gains at 1-year follow-up, with no significant advantage of D-cycloserine over placebo at any time point. The effects of CBT may not be augmented or accelerated when D-cycloserine is administered after sessions.

Overlap and specificity of genetic and environmental influences on excessive acquisition and difficulties discarding possessions: Implications for hoarding disorder.

A reluctance to discard items, leading to severely cluttered living spaces, is the landmark feature of hoarding disorder (HD). Many, but not all, individuals with HD also excessively acquire, buy or even steal items that they do not need and for which no space is available. In DSM-5, "excessive acquisition" can be coded as a specifier of HD. Despite their consistent co-occurrence, the question of whether excessive acquisition and difficulties discarding possessions share a common etiology remains unanswered. The current study sought to flesh out this relationship by examining the extent of shared genetic and environmental influences on the association between excessive acquisition and difficulties discarding in a community sample of adult, female twins. A total of 5,022 female twins (2,529 pairs; mean age = 55.5 years) completed a self-report measure of hoarding symptoms, including items assessing excessive acquisition and difficulties discarding. The data were analyzed using bivariate twin modeling methods in the statistical program Mx. As expected, we found a strong phenotypic correlation (0.63) between excessive acquisition and difficulty discarding items. Both traits were moderately heritable. The genetic correlation between the traits was estimated to be 0.77 (95% CI: 0.69-0.85), indicating a substantial but imperfect genetic overlap. The non-shared environmental correlation (0.50 [95% CI: 0.42-0.57]), though lower, was also significant. The findings demonstrate a substantial genetic, and more modest environmental, etiological overlap between the excessive acquisition of possessions and difficulties discarding them, providing a possible explanation for their frequent co-occurrence in HD. However, given that the etiological overlap is not perfect, unique etiological influences, particularly environmental, on each phenotype seem plausible.

Prevalence and heritability of skin picking in an adult community sample: a twin study.

Skin-picking disorder (SPD) is a disabling psychiatric condition that can lead to skin damage and other medical complications. Epidemiological data is scarce and its causes are unknown. The present study examined the prevalence and heritability of skin-picking symptoms in a large sample of twins. A total of 2,518 twins completed a valid and reliable self-report measure of skin-picking behavior. The prevalence of clinically significant skin picking was established using empirically derived cut-offs. Twin modeling methods were employed to decompose the variance in the liability to skin picking into additive genetic and shared and non-shared environmental factors. A total of 1.2% of twins scored above the cut-off, indicative of clinically significant skin picking. All these participants were women. Univariate model-fitting analyses (female twins only, N = 2,191) showed that genetic factors accounted for approximately 40% (95% CI 19-58%) of the variance in skin picking, with non-shared environmental factors and measurement error accounting for the remaining variance (60% [95% CI 42-81%]). Shared environmental factors were negligible. It is concluded that pathological skin picking is relatively prevalent problem, particularly among women, and that it tends to run in families primarily due to genetic factors. Non-shared environmental factors are also likely to play an important role in its etiology.

Evidence for a genetic overlap between body dysmorphic concerns and obsessive-compulsive symptoms in an adult female community twin sample.

Body dysmorphic disorder (BDD) is thought to be etiologically related to obsessive-compulsive disorder (OCD) but the available evidence is incomplete. The current study examined the genetic and environmental sources of covariance between body dysmorphic and obsessive-compulsive symptoms in a community sample of adult twins. A total of 2,148 female twins (1,074 pairs) completed valid and reliable measures of body dysmorphic concerns and obsessive-compulsive symptoms. The data were analyzed using bivariate twin modeling methods and the statistical programme Mx. In the best-fitting model, the covariation between body dysmorphic and obsessive-compulsive traits was largely accounted for by genetic influences common to both phenotypes (64%; 95% CI: 0.50-0.80). This genetic overlap was even higher when specific obsessive-compulsive symptom dimensions were considered, with up to 82% of the phenotypic correlation between the obsessing and symmetry/ordering symptom dimensions and dysmorphic concerns being attributable to common genetic factors. Unique environmental factors, although influencing these traits individually, did not substantially contribute to their covariation. The results remained unchanged when excluding individuals reporting an objective medical condition/injury accounting for their concern in physical appearance. The association between body dysmorphic concerns and obsessive-compulsive symptoms is largely explained by shared genetic factors. Environmental risk factors were largely unique to each phenotype. These results support current recommendations to group BDD together with OCD in the same DSM-5 chapter, although comparison with other phenotypes such as somatoform disorders and social phobia is needed.

Effectiveness of Multimodal Treatment for Young People With Body Dysmorphic Disorder in Two Specialist Clinics.

Body dysmorphic disorder (BDD) typically originates in adolescence and is associated with considerable adversity. Evidence-based treatments exist but research on clinical outcomes in naturalistic settings is extremely scarce. We evaluated the short- and long-term outcomes of a large cohort of adolescents with BDD receiving specialist multimodal treatment and examined predictors of symptom improvement. We followed 140 young people (age range 10-18) with a diagnosis of BDD treated at two national and specialist outpatient clinics in Stockholm, Sweden (n = 96) and London, England (n = 44), between January 2015 and April 2021. Participants received multimodal treatment consisting of cognitive behavior therapy and, in 72% of cases, medication (primarily selective serotonin reuptake inhibitors). Data were collected at baseline, posttreatment, and 3, 6, and 12 months after treatment.The primary outcome measure was the clinician-rated Yale-Brown Obsessive-Compulsive Scale Modified for BDD, Adolescent version (BDD-YBOCS-A). Secondary outcomes included self-reported measures of BDD symptoms, depressive symptoms, and global functioning. Mixed-effects regression models showed that BDD-YBOCS-A scores decreased significantly from baseline to posttreatment (coefficient [95% confidence interval] = -16.33 [-17.90 to -14.76], p<0.001; within-group effect size (Cohen's d) = 2.08 (95% confidence interval, 1.81 to 2.35). At the end of the treatment, 79% of the participants were classified as responders and 59% as full or partial remitters. BDD symptoms continued to improve throughout the follow-up. Improvement was also seen on all secondary outcome measures. Linear regression models identified baseline BDD symptom severity as a predictor of treatment outcome at posttreatment, but no consistent predictors were found at the 12-month follow-up. To conclude, multimodal treatment for adolescent BDD is effective in both the short- and long-term when provided flexibly within a specialist setting. Considering the high personal and societal costs of BDD, specialist care should be made more widely available.

Are body dysmorphic symptoms dimensional or categorical in nature? A taxometric investigation in adolescents.

Body dysmorphic disorder (BDD) is a debilitating mental health condition which usually emerges during adolescence and is characterised by distressing and impairing appearance concerns. It is currently unclear whether body dysmorphic concerns represent an extreme manifestation of normal appearance concerns (a dimensional conceptualisation), or whether they are qualitatively distinct (a categorical conceptualisation). This study aimed to determine whether body dysmorphic symptoms are dimensional or categorical in nature by investigating the latent structure using taxometric procedures. Body dysmorphic symptoms were assessed using validated measures among 11-16-year-old school pupils (N=707). Items of the Body Image Questionnaire Child and Adolescent version were used to construct four indicators that broadly corresponded to the DSM-5 diagnostic criteria for BDD (appearance concerns, repetitive behaviours, impairment, and insight). Indicators were submitted to three non-redundant taxometric procedures (MAMBAC, MAXEIG and L-MODE). Overall, results of all three taxometric procedures indicated a dimensional latent structure of body dysmorphic symptoms. The current study provides preliminary evidence that body dysmorphic symptoms are continuously distributed among adolescents, with no evidence of qualitative differences between mild and severe symptoms. Implications for clinical practice and research are discussed.

The Role of Paternal Accommodation of Paediatric OCD Symptoms: Patterns and Implications for Treatment Outcomes.

Family accommodation (FA) refers to the participation of family members in obsessive-compulsive disorder (OCD) rituals. Most studies have focused on maternal accommodation; consequently, little is known about fathers' accommodation of OCD. The current study aims to extend the existing literature by examining maternal versus paternal accommodation of OCD symptoms.The sample consisted of 209 children with OCD (Mean [M] age = 14.1 years) and their parents (NMothers = 209, NFathers = 209) who had completed the Family Accommodation Scale- Parent Report (FAS-PR). Paired t-test and chi-square analyses were used to compare FA of OCD symptoms between mothers and fathers. Linear regression was used to examine correlates of maternal and paternal FA and its impact on treatment outcomes.Mothers reported significantly higher levels of daily FA than fathers. Correlates of maternal and paternal accommodation included OCD symptom severity, emotional and behavioral difficulties, and parent psychopathology. Both maternal and paternal FA significantly predicted worse treatment outcomes.Both mothers and fathers accommodate child OCD symptoms with high frequency, and in similar ways. Although mothers accommodate to a greater extent than fathers, both maternal and paternal involvement in rituals are a significant predictor of the child's treatment response. Results emphasise the need to consider the whole family system, including fathers, in understanding and treating OCD in children.

The duration of inpatient admission predicts cognitive functioning at discharge in patients with bipolar disorder.

Previous studies of cognitive functioning in bipolar disorder generally indicate that a more severe course of illness is associated with greater cognitive impairment. In particular, a history of greater number and longer duration of mood episodes predicts enduring cognitive deficits in euthymic patients. Shifting the focus of this investigation to the cognitive effects of a discrete mood episode, the current study aimed to explore whether patients who require a longer hospitalization to stabilize from an acute episode of mood disturbance present with more compromised cognitive functioning during the phase of early recovery. For this purpose, the study examined the link between the duration of inpatient admission and neuropsychological test scores at the time of discharge in 41 patients with bipolar disorder. Participants were assigned to long (n = 20) and short (n = 21) stay groups using a median split (M = 12). Results indicated that longer admissions were associated with more severe deficits in executive functioning at discharge after controlling for residual mood symptoms and previous number of psychiatric admissions. Findings from the current study may inform discharge planning for patients with bipolar disorder after an extended hospital stay.

Changes in Dosing and Dose Timing of D-Cycloserine Explain Its Apparent Declining Efficacy for Augmenting Exposure Therapy for Anxiety-related Disorders: An Individual Participant-data Meta-analysis.

The apparent efficacy of d-cycloserine (DCS) for enhancing exposure treatment for anxiety disorders appears to have declined over the past 14 years. We examined whether variations in how DCS has been administered can account for this "declining effect". We also investigated the association between DCS administration characteristics and treatment outcome to find optimal dosing parameters. We conducted a secondary analysis of individual participant data obtained from 1047 participants in 21 studies testing the efficacy of DCS-augmented exposure treatments. Different outcome measures in different studies were harmonized to a 0-100 scale. Intent-to-treat analyses showed that, in participants randomized to DCS augmentation (n = 523), fewer DCS doses, later timing of DCS dose, and lower baseline severity appear to account for this decline effect. More DCS doses were related to better outcomes, but this advantage leveled-off at nine doses. Administering DCS more than 60 minutes before exposures was also related to better outcomes. These predictors were not significant in the placebo arm (n = 521). Results suggested that optimal DCS administration could increase pre-to-follow-up DCS effect size by 50%. In conclusion, the apparent declining effectiveness of DCS over time may be accounted for by how it has been administered. Optimal DCS administration may substantially improve outcomes. Registration: The analysis plan for this manuscript was registered on Open Science Framework (https://osf.io/c39p8/).

Neurocognitive impairment in patients with co-occurring bipolar disorder and alcohol dependence upon discharge from inpatient care.

The current study explored the neurocognitive functioning of patients with co-occurring bipolar disorder and alcohol dependence upon discharge from inpatient care. The study compared scores of neuropsychological tests among three groups of bipolar I inpatients without a history of neurological injury or illness: 1) patients meeting DSM-IV diagnostic criteria for alcohol dependence in the past 6 months (n=13), 2) patients diagnosed with alcohol dependence in full remission (n=9), and 3) patients without a history of a substance use disorder (SUD; n=41). Analyses indicated that patients with co-occurring alcohol dependence exhibited more severe impairment on tests of executive functioning (i.e. Stroop Color-Word Interference Test, Wisconsin Card Sorting Test) than patients without SUD. In addition, the group meeting diagnostic criteria for alcohol dependence in the past 6 months exhibited greater decrements in verbal (California Verbal Learning Test--II) and visual (Rey Complex Figure Test) memory. Analysis further indicated that patients in full SUD remission scored lower on measures of fluid intelligence (Wechsler Abbreviated Scale of Intelligence--Performance IQ). Consistent with previous reports, in the current sample, co-occurring alcohol dependence predicted higher rates of disability status. It is possible that cognitive deficits of greater severity in dually diagnosed patients contribute to this unfavorable outcome. Recognizing the extent of cognitive impairment in dually diagnosed patients may facilitate the effort to ameliorate their condition.

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.

D-Cycloserine Augmentation of Exposure-Based Cognitive Behavior Therapy for Anxiety, Obsessive-Compulsive, and Posttraumatic Stress Disorders: A Systematic Review and Meta-analysis of Individual Participant Data.

Importance: Whether and under which conditions D-cycloserine (DCS) augments the effects of exposure-based cognitive behavior therapy for anxiety, obsessive-compulsive, and posttraumatic stress disorders is unclear. Objective: To clarify whether DCS is superior to placebo in augmenting the effects of cognitive behavior therapy for anxiety, obsessive-compulsive, and posttraumatic stress disorders and to evaluate whether antidepressants interact with DCS and the effect of potential moderating variables. Data Sources: PubMed, EMBASE, and PsycINFO were searched from inception to February 10, 2016. Reference lists of previous reviews and meta-analyses and reports of randomized clinical trials were also checked. Study Selection: Studies were eligible for inclusion if they were (1) double-blind randomized clinical trials of DCS as an augmentation strategy for exposure-based cognitive behavior therapy and (2) conducted in humans diagnosed as having specific phobia, social anxiety disorder, panic disorder with or without agoraphobia, obsessive-compulsive disorder, or posttraumatic stress disorder. Data Extraction and Synthesis: Raw data were obtained from the authors and quality controlled. Data were ranked to ensure a consistent metric across studies (score range, 0-100). We used a 3-level multilevel model nesting repeated measures of outcomes within participants, who were nested within studies. Results: Individual participant data were obtained for 21 of 22 eligible trials, representing 1047 of 1073 eligible participants. When controlling for antidepressant use, participants receiving DCS showed greater improvement from pretreatment to posttreatment (mean difference, -3.62; 95% CI, -0.81 to -6.43; P = .01; d = -0.25) but not from pretreatment to midtreatment (mean difference, -1.66; 95% CI, -4.92 to 1.60; P = .32; d = -0.14) or from pretreatment to follow-up (mean difference, -2.98, 95% CI, -5.99 to 0.03; P = .05; d = -0.19). Additional analyses showed that participants assigned to DCS were associated with lower symptom severity than those assigned to placebo at posttreatment and at follow-up. Antidepressants did not moderate the effects of DCS. None of the prespecified patient-level or study-level moderators was associated with outcomes. Conclusions and Relevance: D-cycloserine is associated with a small augmentation effect on exposure-based therapy. This effect is not moderated by the concurrent use of antidepressants. Further research is needed to identify patient and/or therapy characteristics associated with DCS response.