Which Symptoms Bridge Symptoms of Depression and Symptoms of Eating Disorders?: A Network Analysis.

ABSTRACT: Depression is a common comorbid mental illness in eating disorders (EDs). Network theory focuses on interactions between symptoms, but findings from network analyses of EDs and depression need to be replicated to make reliable claims about the nature of symptomatic interplay. We used cross-sectional data of 366 online-recruited participants with clinically elevated ED symptomatology and constructed a regularized partial correlation network with ED and depression symptoms. To determine each symptom's influence, we calculated expected influence (EI) and bridge EI to identify symptoms that bridged symptoms of depression and ED. Concerns that others see one eat, fear of weight gain, and fear of loss of control over eating were especially important among the ED symptoms. Loss of interest and feeling sad were the key depression symptoms. Eating in secret and low self-esteem emerged as potential bridge symptoms between clusters. These findings regarding bridge symptoms partially overlap with prior network analyses in nonclinical and clinical samples. Future studies that investigate symptom interplay via a longitudinal design to deduce causality are needed.

Reliability and Validity of the Self-Report Version of the Yale-Brown Obsessive-Compulsive Scale Modified for Body Dysmorphic Disorder.

Despite its frequent use in research studies, the self-report version of the Yale-Brown Obsessive-Compulsive Scale modified for Body Dysmorphic Disorder (BDD-YBOCS-SR) is yet to be formally validated. The present investigation sought to examine the psychometric properties of the BDD-YBOCS-SR across three different samples. In Study 1 (N = 847), we sought to explore the factor structure of the BDD-YBOCS-SR. In addition, we evaluated the convergent and divergent validity with similar self-report measures. In Study 2 (N = 187), the convergence of the BDD-YBOCS-SR with reactivity to an in vivo appearance-related task was observed. In Study 3, we compared scores on the BDD-YBOCS-SR between a clinical sample of individuals with BDD (n = 50) and a "healthy" control sample (n = 51). We further observed the BDD-YBOCS-SR's sensitivity to treatment and convergence with the rater-administered version in the clinical sample. The BDD-YBOCS-SR demonstrated strong psychometric properties across all three studies. Scores on the BDD-YBOCS-SR were found to be strongly associated with appearance anxiety, reactivity to the appearance task, and the rater-administered BDD-YBOCS. The present investigation provides support for the BDD-YBOCS-SR's utility in measuring body dysmorphic symptom severity for use in research and clinical settings.

A self-report assessment of appearance-related safety behaviours: Development and psychometric properties.

BACKGROUND: Individuals with appearance concerns may engage in maladaptive appearance-related safety behaviours aimed at checking, hiding or fixing perceived flaws in their appearance. AIMS: This investigation examined the psychometric properties of a newly developed measure of appearance-related safety behaviours across three different studies. METHOD: The first two studies utilized exploratory and confirmatory factor analysis, respectively, to understand the factor structure of the measure. The final version of the Appearance-Related Safety Behavior Scale (ARSB) consisted of 13 items and two subscales related to behavioural avoidance and appearance maintenance. RESULTS: Number of appearance-related safety behaviours was positively associated with body dysmorphic disorder symptomology and functional impairment, as well as social anxiety and eating disorder symptoms. The measure also demonstrated convergent validity with other appearance-related measures. Scores on the ARSB also predicted performance on an appearance-related behavioural task (time spent fixing appearance prior to having a picture taken). The third study found that scores on the ARSB were higher in a body dysmorphic disorder sample compared with healthy controls. Furthermore, change in scores on the ARSB was correlated with change in body dysmorphic disorder symptoms and impairment in a treatment study for body dysmorphic disorder. CONCLUSIONS: Clinical implications and potential uses of the measure as a clinical and research tool are discussed.

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.

Feasibility and acceptability of an online mindfulness-based group intervention for adults with tic disorders.

BACKGROUND: Preliminary research suggests that a mindfulness-based treatment approach may be beneficial for adults with tic disorders. In the present study, we report on the feasibility, acceptability, safety, and symptomatic effect of a novel online mindfulness-based group intervention for adults with Tourette syndrome or persistent tic disorder. Data from this study will directly inform the conduct of a funded randomized controlled trial comparing the efficacy of this intervention to another active psychological intervention. METHODS: One cohort of adults with Tourette syndrome participated in an 8-week online mindfulness-based group intervention. Measures of feasibility, acceptability, and safety were administered throughout and at posttreatment. Self-reported measures of mindfulness and clinician-rated measures of tic severity and impairment were administered at baseline and posttreatment. RESULTS: Data on refusal, dropout rate, attendance, participant satisfaction, and safety suggest that this is a feasible and acceptable intervention. However, participant adherence to home practice was lower than anticipated. Mindfulness, tic severity, and tic-related impairment only modestly improved from baseline to posttreatment. Qualitative analysis of participant feedback revealed aspects of the intervention that were most helpful and also areas for improvement. CONCLUSIONS: Data suggest that although this is a feasible and acceptable intervention, it should be modified to enhance participant adherence, more successfully engage the target mechanism, and optimize outcomes. TRIAL REGISTRATION: Clinicaltrials.gov registration # NCT03525626 . Registered on 24 April 2018.

A virtual reality study of cognitive biases in body dysmorphic disorder.

Previous research shows that individuals with body dysmorphic disorder (BDD) misinterpret ambiguous social information in a negative and threatening manner. These erroneous threat appraisals are thought to maintain disorder symptomatology and psychosocial impairment by reinforcing individuals' distorted self-image and ideas of social undesirability. Thus, maladaptive interpretation biases represent an important treatment target for this population; however, existing bias assessments and modification protocols are limited by the hypothetical and distal nature of scenarios and do not capture momentary experiential threat processes. The current study tested virtual reality (VR) technology as a novel, in vivo means of eliciting, identifying, and measuring threat interpretation biases in a clinical sample to better understand the fear/threat structure activated during social interactions in BDD. Findings indicated that, relative to nonpsychiatric controls (N = 25), individuals with BDD (N = 25) evidenced greater in vivo threat interpretation biases and discomfort ratings (distress, fear, perceived threat, urge to check, urge to avoid) in response to interpersonal scenarios presented via VR. This pattern of findings was also observed for established dispositional interpretation bias measures. Study findings enhance our understanding of disorder maintenance and offer more nuanced treatment targets. This study represents a critical first step in the long-term goal of harnessing VR gaming technology to supercharge existing treatment approaches for this debilitating illness. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

A Multimethod Analysis of Incompleteness and Visual "Not Just Right" Experiences in Body Dysmorphic Disorder.

Individuals with body dysmorphic disorder (BDD) often report engaging in repetitive behaviors aimed at reducing feelings of imperfection anchored to their appearance. "Not just right" experiences (NJREs) and incompleteness (INC) are constructs related to perfectionism that have traditionally been studied in obsessive-compulsive disorder, though recent research has also linked these phenomena to BDD. We sought to replicate and extend this research via two studies. Study 1 examined BDD symptoms, INC, as well as harm avoidance (HA) in an unselected sample (N = 179); moderate associations were observed between symptoms and both INC and HA. Participants also completed a novel visual NJRE task in which they were shown appearance-related and non-appearance-related images meant to evoke an NJRE response (i.e., discomfort and urge to "fix" stimuli). BDD symptoms predicted reactivity to appearance-related NJRE stimuli above negative affect. Study 2 compared INC, HA, and task reactivity in a BDD sample (N = 50) to nonpsychiatric controls (N = 44). The BDD group evidenced greater INC, HA, and reactivity to both appearance and nonappearance NJRE stimuli, relative to controls; however, group differences did not remain after controlling for age and negative affect. These studies broadly corroborate previous research highlighting NJREs and INC as potential vulnerability factors relevant to BDD, though these phenomena may not be specific to BDD symptoms.

Development and Pilot Testing of a Cognitive-Behavioral Therapy Digital Service for Body Dysmorphic Disorder.

Body dysmorphic disorder (BDD) has a severe presentation and chronic course when untreated. Although effective BDD treatments exist, most individuals do not have access to them. We therefore developed and pilot tested the first smartphone-delivered individual cognitive-behavioral therapy (CBT) treatment for adults with BDD. The digital service was developed via user-centered design, integrating input from engineering, design, and psychology experts, plus BDD patient consultants. We conducted a 12-week open pilot trial (N = 10) to describe preliminary results for feasibility, acceptability, and treatment outcome. Attrition rates (0%) and feedback on usability and satisfaction indicated that smartphone-based CBT for BDD may be feasible, acceptable, and satisfactory. Initial results suggest that smartphone-based CBT for BDD may hold promise for improving BDD symptom severity, BDD-related insight, functional impairment, and quality of life, as scores from baseline to posttreatment improved with large-to-very large effects; depression improved with a medium effect. Ninety percent of participants were responders at posttreatment and 3-month follow-up. Smartphone-based CBT for BDD may have strong potential as a standardized, low cost, and accessible treatment for this debilitating illness. A test of efficacy is merited as a next step, using a well-powered, randomized control trial design.

Interpretation Bias Modification Versus Progressive Muscle Relaxation for Social Anxiety Disorder: A Web-Based Controlled Trial.

Computerized interpretation bias modification (IBM) programs show promise for the treatment of anxiety disorders, though they have rarely been compared to active treatments. The goal of the present study was to compare the efficacy of IBM to progressive muscle relaxation (PMR) for the treatment of social anxiety disorder (SAD). Sixty-four participants with SAD were recruited from across the United States and randomly assigned to 8 internet-delivered twice-weekly sessions of IBM or PMR. Participants were administered assessments of primary symptom outcomes and interpersonal suicide risk factors at posttreatment and 3-month follow-up. IBM led to significantly lower negative interpretation bias than PMR at posttreatment but not follow-up. Both conditions experienced comparable reductions in social anxiety from pretreatment to follow-up (IBM d = 1.37, PMR d = 1.28). They also experienced significant reductions in depression and general anxiety that did not differ from one another. Additionally, IBM led to greater reductions in thwarted belongingness than PMR at posttreatment but not follow-up. Overall, these findings suggest IBM is not more effective than PMR for reducing social anxiety, though there was some evidence of its superiority in decreasing suicide risk. Limitations and directions for future research are discussed.

Effects of safety behavior fading on appearance concerns and related symptoms.

OBJECTIVE: Appearance-related safety behaviors (SBs; e.g., mirror checking, grooming) have been implicated in body dysmorphic disorder (BDD), eating disorders, and social anxiety disorder. The proposed project aimed to extend previous research efforts by exploring the experimental effects of reducing engagement in appearance-related SBs on appearance concerns and related symptoms. METHOD: Eighty-four undergraduate female participants with elevated appearance concerns were randomly assigned to a SB fading group or a no instructions control group. For 2 weeks, participants in the SB fading condition were sent daily reminders via text message to decrease their engagement in appearance-related SBs, whereas participants in the control group completed assessments only. Self-report assessments of study variables of interest were administered at baseline, midmanipulation, postmanipulation, and 2-week follow-up. Participants also completed an appearance-related in vivo stressor task at post, during which participants rated their reactivity to having their photographs taken from various angles. RESULTS: Compared to the control group, the SB fading group exhibited significantly lower social anxiety, BDD symptoms, body dissatisfaction, and maladaptive cognitions at the postmanipulation and follow-up assessments. SB fading had stronger effects on BDD symptoms at postmanipulation among those high versus those low in baseline BDD symptoms. The SB fading group also showed less reactivity to some aspects of the in vivo appearance-related stressor task. CONCLUSIONS: This study provides strong evidence for the importance of appearance-related SBs in the maintenance of BDD and other disorders characterized by body image disturbances. Findings point to the potential utility of decreasing appearance-related SBs as a transdiagnostic treatment strategy. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

A network perspective on body dysmorphic disorder and major depressive disorder.

BACKGROUND: Body dysmorphic disorder (BDD) is a highly debilitating mental disorder associated with notable psychosocial impairment and high rates of suicidality. This study investigated BDD from a network perspective, which conceptualizes mental disorders as systems of symptoms that cause and exacerbate one another (e.g., preoccupation with perceived appearance defect triggering compulsive checking in the mirror). METHODS: In a sample of BDD patients (N = 148), we used cross-sectional network models to explore the network structure of 1) BDD symptoms and 2) BDD symptoms and major depressive disorder (MDD) symptoms, and tested which symptoms were most central (i.e., most strongly associated to other symptoms). RESULTS: Interference in functioning due to appearance-related compulsions (BDD), feelings of worthlessness (MDD), and loss of pleasure (MDD) were most central. CONCLUSION: These symptoms were most strongly predictive of other BDD and MDD symptoms and may be features of BDD that warrant prioritization in theory development and treatment. A limitation of our study is that the precision of these findings may be limited due to a small sample size relative to the number of parameters. Replication studies in larger samples of BDD patients are needed.

An experimental test of the role of appearance-related safety behaviors in body dysmorphic disorder, social anxiety, and body dissatisfaction.

Individuals with appearance concerns engage in "safety behaviors" (SBs) aimed at checking, hiding, fixing, and reducing threat associated with their perceived flaw in appearance. Appearance-related SBs are important in contemporary accounts of body dysmorphic disorder (BDD), though they are also relevant to social anxiety (SAD) and eating disorders. The present study examined the extent to which appearance-related SBs contribute to the development of disorder-specific symptoms and maladaptive cognitions. Female undergraduates without clinically elevated appearance concerns (N = 99) were randomly assigned to 1 week of (a) increasing the frequency and duration of appearance-related SBs (SB+), (b) decreasing these behaviors (SB-), or (c) a control in which they increased their academic studying behaviors. Generally, SB+ participants demonstrated greater BDD symptoms, SAD symptoms, body dissatisfaction, disorder-relevant threat interpretations, beliefs about the importance of appearance, and reactivity to an in vivo appearance-related task following the manipulation, relative to the other groups, with some exceptions. The SB- and control conditions largely did not differ from one another in these outcomes. SB+ participants also reported greater anxiety and depressive symptoms postmanipulation relative to other conditions. Groups no longer differed from one another at a follow-up assessment. Overall, these findings suggest that engagement in appearance-related SBs may play an instrumental role in symptoms and maladaptive cognitions across a range of disorders. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

An initial investigation of the unique relationship between disgust propensity and body dysmorphic disorder.

Disgust is a universal emotion that has received recent empirical attention for its potential role in various forms of psychopathology. We conducted two studies using varying methods to explore the relationship between disgust propensity, a construct related to obsessive-compulsive symptomatology, and symptoms of body dysmorphic disorder (BDD). Study 1 found a significant and unique (i.e., above and beyond co-occurring depression and anxiety) relationship between higher disgust propensity and more severe BDD symptoms, as measured by a standardized self-report and via an in-vivo task aimed at eliciting BDD-related concerns (N = 200). In Study 2, a clinical sample of individuals with BDD (N = 50) reported higher disgust propensity compared to mentally healthy controls (N = 36). This finding remained significant when controlling for depression and anxiety. Findings are the first to our knowledge to demonstrate a relationship between disgust propensity and BDD symptoms and provide directions for future research exploring the role of disgust in BDD.

"Not just right" experiences account for unique variance in eating pathology.

"Not just right" experiences (NJREs) are uncomfortable sensations of incompleteness linked to obsessive-compulsive disorder; however, NJREs may be transdiagnostic and play a role in eating pathology. The current study examined relations between NJREs and eating pathology in undergraduate students. Participants (n = 248) completed self-report and behavioral assessments. Controlling for obsessive-compulsive symptoms, negative affect, and perfectionism, NJRE frequency was associated with greater drive for thinness, body dissatisfaction, and bulimic symptoms. Discomfort in response to a visual in vivo NJRE task was positively associated with drive for thinness and body dissatisfaction. The present study provides initial evidence for NJREs in eating pathology. Theoretical implications are discussed.

Effects of an Appearance-Focused Interpretation Training Intervention on Eating Disorder Symptoms.

BACKGROUND: Previous research suggests that computerized interpretation bias modification (IBM) techniques may be useful for modifying thoughts and behaviours relevant to eating pathology; however, little is known about the utility of IBM for decreasing specific eating disorder (ED) symptoms (e.g. bulimia, drive for thinness). AIMS: The current study sought to further examine the utility of IBM for ED symptoms via secondary analyses of an examination of IBM for individuals with elevated body dysmorphic disorder (BDD) symptoms (see Summers and Cougle, 2016), as these disorders are both characterized by threat interpretation biases of ambiguous appearance-related information. METHOD: We recruited 41 participants for a randomized trial comparing four sessions of IBM aimed at modifying problematic social and appearance-related threat interpretation biases with a placebo control training (PC). RESULTS: At 1-week post-treatment, and relative to the PC, the IBM group reported greater reductions in negative/threat interpretations of ambiguous information in favour of positive/benign biases. Furthermore, among individuals with high pre-treatment bulimia symptoms, IBM yielded greater reductions in bulimia symptoms compared with PC at post-treatment. No treatment effects were observed on drive for thinness symptoms. CONCLUSIONS: The current study suggests that cognitive interventions for individuals with primary BDD symptoms may improve co-occurring ED symptoms such as bulimia.

Six In Vivo Assessments of Compulsive Behavior: A Validation Study Using the Obsessive-Compulsive Inventory-Revised.

Due to the complex and heterogeneous nature of obsessive-compulsive disorder (OCD), movement toward multimodal assessment has become necessary to more precisely understand the nature of the disorder and interrelations between symptom clusters. Thus, the present study utilized large undergraduate samples (total N = 800) to test the validity of six in vivo assessments of OC symptoms (i.e., one ordering/arranging task, two contamination fear/washing tasks, and three checking tasks). Associations between task-specific variables and self-reported symptom scores (as measured by the Obsessive-Compulsive Inventory-Revised [OCI-R]) were examined. The majority of the in vivo task variables (those presented in Studies 1-4) exhibited significant relationships with the corresponding OCI-R symptom subscale (i.e., ordering, washing, checking). However, many of the task variables demonstrated relationships with other OCI-R symptom subscales, as well. Some evidence for discriminant validity was found, as task variables were generally unrelated to past-week symptoms of depression or anxiety. While continued research is necessary to further establish the validity and utility of the tasks discussed in the current article, findings have implications for improving future empirical examination of OC symptoms.

Hostile interpretation training for individuals with alcohol use disorder and elevated trait anger: A controlled trial of a web-based intervention.

High trait anger is associated with more severe alcohol use problems, and alcohol has been found to facilitate aggressive behavior among individuals with high trait anger. Treatments focused on a sample with alcohol use disorder with elevated anger could reduce alcohol use problems, as well as violence and aggression. We sought to examine the efficacy of interpretation bias modification for hostility (IBM-H) in a sample with high trait anger and alcohol use disorder (AUD). Fifty-eight individuals with AUD and elevated trait anger were randomly assigned to eight web-based sessions (two per week) of IBM-H or a healthy video control condition (HVC). Measures of interpretation bias, anger, and alcohol use were administered at pre- and post-treatment and at one-month follow-up. IBM-H led to greater improvements in interpretation bias compared to HVC at post and follow-up. IBM-H also led to greater reductions in trait anger than HVC, though this was an indirect effect mediated by changes in interpretation bias. Further, IBM-H led to lower anger expression than HVC; this was a direct (non-mediated) effect. Lastly, both conditions reported decreases in alcohol use and consequences following treatment, though there were no significant differences between them. These findings provide initial support for the utility of IBM-H as a brief non-confrontational intervention for AUD with elevated trait anger. Limitations and future research directions are discussed.

A multi-method analysis of distress tolerance in body dysmorphic disorder.

Distress tolerance (DT) is a transdiagnostic construct linked to multiple psychiatric disorders. We conducted three studies using different methods to investigate the relationship between DT and body dysmorphic disorder (BDD). Study 1 found a significant relationship between low DT and more severe BDD symptoms in an adult community sample (N=81). In Study 2, we found a similar relationship between lower DT and greater BDD symptoms in a student sample (N=192). Furthermore, we found a unique relationship between greater BDD symptoms and lower self-reported tolerance of anger and sadness mood induction tasks. Greater BDD symptoms were not significantly associated with lower self-reported tolerance of a fear mood induction task. In Study 3, a clinical sample of individuals with BDD (N=40) reported lower DT than a sample of healthy controls (N=36). Findings suggest that low DT is a broad vulnerability factor related to BDD.

'Not just right' experiences and incompleteness in body dysmorphic disorder.

The current studies examined the role of 'not just right' experiences (NJREs) and incompleteness (INC) in body dysmorphic disorder (BDD). In Study 1, a clinical BDD sample endorsed more severe NJREs than healthy controls, when controlling co-occurring symptoms of depression and anxiety. In Study 2, INC predicted reactivity to an in vivo task designed to evoke BDD-related concerns in an unselected sample. Study 3 demonstrated a positive relationship between INC and BDD symptom severity in a community sample. Study 4 examined in vivo sensory NJRE tasks and INC in a sample high and low in BDD symptoms. The high symptom group reported greater INC and reactivity to a visual NJRE task than their low symptom counterparts, when controlling for co-occurring symptoms of depression, anxiety, and OC symptoms. No group differences were observed for tasks assessing auditory and tactile NJREs. These studies demonstrate a unique relationship between INC/NJREs and BDD.

Modifying interpretation biases in body dysmorphic disorder: Evaluation of a brief computerized treatment.

Individuals meeting diagnostic criteria for body dysmorphic disorder (BDD; N = 40) were enrolled in a randomized, four-session trial comparing interpretation bias modification (IBM) training designed to target social evaluation- and appearance-related interpretation biases with a placebo control training condition (PC). Sessions took place over the course of two weeks (two sessions per week). Analyses indicated that, relative to the PC condition, IBM led to a significant increase in benign biases and reduction in threat biases at post-treatment. IBM also led to greater reductions in BDD symptoms compared to PC, though this effect was present at high but not low levels of pre-treatment BDD symptoms. Additionally, compared to PC, IBM led to lower urge to check and lower fear in response to an in vivo appearance-related stressor (having their picture taken from different angles), though the latter effect was present only among those reporting elevated fear at pre-treatment. The effects of treatment on interpretation biases and BDD symptoms were largely maintained at a one-month follow-up assessment. Moderated-mediation analyses showed that change in threat bias mediated the effect of condition on post-treatment symptoms for individuals high in pre-treatment BDD symptoms. The current study provides preliminary support for the efficacy of IBM for BDD.