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

BACKGROUND: Body dysmorphic disorder (BDD) is a severe, chronic disorder if untreated. Smartphone cognitive behavioral therapy (CBT) for BDD is efficacious and can reduce key treatment barriers (e.g., lack of clinicians, cost, stigma). While promising, little is known about who is more or less likely to benefit from this approach. METHODS: This is a secondary data analysis of a randomized, waitlist-controlled trial of smartphone CBT for BDD. Participants (N = 80) were recruited nationally and randomized to receive a 12-week, coach-guided CBT for BDD app, either immediately or after a 12-week waitlist. The main outcome for this analysis was BDD severity (BDD-YBOCS) over time (baseline, week 6, week 12) during the active app use phase in each randomized group (n = 74). Secondary outcomes included treatment response (≥30 % reduction in BDD-YBOCS) and remission (total BDD-YBOCS ≤16) at end-of-treatment. RESULTS: Immediate (vs. delayed) CBT predicted better outcomes (symptom improvement), as did gender identity (symptom improvement), higher baseline treatment credibility and expectancy (response, remission), lower baseline BDD severity (remission), and sexual minority status (vs. heterosexual; response, remission). LIMITATIONS: Limitations include the relatively small sample, drop-out rate of 22 %, and limited gender and racial-ethnic diversity. CONCLUSIONS: These results highlight a potential advantage of smartphone CBT in historically marginalized populations, and the importance of efforts to hasten treatment access, bolster confidence in the treatment at treatment onset, and develop stratified care models to optimize treatment allocation and efficacy.

Enhancing self-esteem in adults with body dysmorphic symptoms: experimental testing and initial evaluation of a brief internet-based training.

BACKGROUND: Low self-esteem is an important factor associated with body dysmorphic concerns. In treatment, self-esteem cannot always be adequately addressed. Internet-based interventions offer a low-threshold and cost-efficient possibility for treating body dysmorphic disorder (BDD). AIMS: For this reason, we conducted two studies to explore the effectiveness of an internet-based intervention targeting improving self-esteem in adults with BDD symptoms. METHOD: The first study investigated the differential effects of a 1-week self-esteem training compared with a 1-week attention-focus training. Two hundred twenty adults with elevated body dysmorphic symptoms were randomly assigned to one of the two trainings. Our second study (n = 58 adults with body dysmorphic symptoms) evaluated an extended 2-week stand-alone self-esteem training. RESULTS: In the first study, self-esteem in different domains (appearance, performance and social), self-focused attention, and BDD symptom severity improved in both groups. Other-focused attention only increased in the attention training group. Participants' overall adherence was high. In the second study we observed significant improvements in self-esteem, BDD symptom severity, and other secondary outcomes, with additional improvements in most outcomes in the second week. Adherence was again high. CONCLUSIONS: Together, these findings show that a brief internet-based intervention may be a highly accepted and effective way of improving self-esteem in people suffering from BDD symptoms.

Is cognitive behavioral therapy an efficacious treatment for psychological interventions in body dysmorphic disorders? A meta-analysis based on current evidence from randomized controlled trials.

BACKGROUND: Clinical guidelines and some studies recommend cognitive-behavioral therapy (CBT) as the most effective treatment for body dysmorphic disorder (BDD). However, owing to the lack of randomized controlled trials (RCTs), the research evidence is insufficient. This study aimed to explore the effectiveness of CBT in the treatment of BDD using RCTs. This meta-analysis was registered in PROSPERO (CRD42023410577). METHODS: After a literature search and screening, 11 RCTs with 667 patients were included. The ROB 2.0 tool, funnel plots, sensitivity analysis, and meta-regression analysis were used to assess the quality, publication bias, and sources of heterogeneity. RESULTS: After CBT intervention, the severity of BDD (SMD = -1.73, 95 % CI (confidence interval) = [-2.90; -0.57]), depression symptoms (SMD = -1.72, 95 % CI = [-3.16; -0.28]), and anxiety levels were all reduced in the patients of the experimental group; the remission of BDD (OR = 7.37, 95 % CI = [2.17; 24.98]) and the response of BDD (OR = 8.86, 95 % CI = [4.85; 16.18]) were all increased; incorrect beliefs such as disability and BABS were also reduced; the quality of life was improved. The difference between the groups was statistically significant (p < 0.01). Meta-regression analysis showed that age and sample size were the predictive factors of the effectiveness of CBT. LIMITATIONS: The heterogeneity of most meta-analyses was high (I2 > 75 %). CONCLUSIONS: Although CBT is effective in treating BDD, there is insufficient evidence to suggest that it is the best psychological intervention for BDD. More high-quality evidence is still needed in the future.

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.

Time to Response in Therapy for Body Dysmorphic Disorder: A Comparison of Cognitive Behavioral Therapy and Supportive Psychotherapy.

Psychotherapy has been shown to be effective for individuals with body dysmorphic disorder (BDD); however, time to treatment response for different treatments have not yet been examined. We randomized 120 patients to either weekly cognitive behavioral therapy (CBT) or supportive psychotherapy (SPT) at two academic medical research centers. In this secondary data analysis, we aimed to determine the time to first response (30% or greater reduction in BDD symptom severity) in both treatment conditions among those who attended at least one post-baseline assessment (n = 109). As previously reported, CBT for BDD was associated with more consistent improvement in symptom severity and quality of life than SPT. In a pooled analysis combining both sites, the median time to first response was shorter for CBT (76 days [10.9 weeks], 95% CI: 76-107 days) than for SPT (88 days [12.6 weeks], 95% CI: 88-nonestimable days; Χ2df=1 = 3.85, p = .0498). For CBT, the estimated 75th percentile response times were 148 days [21.1 weeks] at site 1 and 134 days [19.1 weeks] at site 2. Response times were not estimable for SPT at either site because the response rate was too low. Thus, therapy clients seeking treatment for BDD and clinicians should be aware that an initial treatment response requires more than 11 therapy sessions for the majority of clients, and that 21 or even more sessions may be required. Treatment response is likely to occur earlier with CBT for BDD (the first-line therapy for BDD) than with supportive psychotherapy.

[Towards perfection: the ethical downside of the ideal of beauty]. / Op weg naar perfectie: de ethische keerzijde van het schoonheidsideaal.

Beauty, it seems, is a fascination inherent in human nature. Research shows that an attractive face plays a significant factor in human life, such as in the areas of appreciation and judgment.The growing demand for cosmetic treatments is amplified by social media and influencer marketing. However, there are possible negative effects, such as addiction and dissatisfaction with treatment outcome in people with Body Dysmorphic Disorder. It remains important to recognize that risks are inherent in medical procedures.

Internet-Based Treatment of Body Dysmorphic Disorder: Feasibility, Evaluation, and Self-Report Data.

ABSTRACT: Initial findings indicate the effectiveness of internet-based interventions for body dysmorphic disorder (BDD). In order to substantiate these findings, a seven-module guided internet-based intervention was created and examined. We report the mixed data of participants with clinical and subclinical BDD of the treatment group (n = 18). We investigated the feasibility, the quality of the program content, the design and usability, and its effects on symptom severity and related psychopathology. Adherence to the intervention was low and dropout rate high (55.6%). The program content, perceived website usability, and visual aesthetic were rated high. Credibility and expectancy were on a medium level. Satisfaction with appearance improved significantly in the intention-to-treat analysis (d = 0.58). In sum, symptom-related outcomes and program evaluation showed a positive trend albeit the study conduction was difficult. Future programs should investigate the role of additional motivation strategies and more flexible support addressing the known treatment barriers.

Body Dysmorphic Disorder in Women.

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

Mechanisms of cognitive-behavioral therapy effects on symptoms of body dysmorphic disorder: a network intervention analysis.

BACKGROUND: Body dysmorphic disorder (BDD) is a severe and undertreated condition. Although cognitive-behavioral therapy (CBT) is the first-line psychosocial treatment for this common disorder, how the intervention works is insufficiently understood. Specific pathways have been hypothesized, but only one small study has examined the precise nature of treatment effects of CBT, and no prior study has examined the effects of supportive psychotherapy (SPT). METHODS: This study re-examined a large trial (n = 120) comparing CBT to SPT for BDD. Network intervention analyses were used to explore symptom-level data across time. We computed mixed graphical models at multiple time points to examine relative differences in direct and indirect effects of the two interventions. RESULTS: In the resulting networks, CBT and SPT appeared to differentially target certain symptoms. The largest differences included CBT increasing efforts to disengage from and restructure unhelpful thoughts and resist BDD rituals, while SPT was directly related to improvement in BDD-related insight. Additionally, the time course of differences aligned with the intended targets of CBT; cognitive effects emerged first and behavioral effects second, paralleling cognitive restructuring in earlier sessions and the emphasis on exposure and ritual prevention in later sessions. Differences in favor of CBT were most consistent for behavioral targets. CONCLUSIONS: CBT and SPT primarily affected different symptoms. To improve patient care, the field needs a better understanding of how and when BDD treatments and treatment components succeed. Considering patient experiences at the symptom level and over time can aid in refining or reorganizing treatments to better fit patient needs.

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

BACKGROUND AND OBJECTIVES: Mindfulness-based cognitive therapy (MBCT) is garnering increasing empirical interest as an intervention for Body Dysmorphic Disorder (BDD), although no studies of mindfulness as a standalone treatment have included a sample composed entirely of patients with BDD or a comparison group. The aim of this study was to investigate the improvement of MBCT intervention on the core symptoms, emotional dysfunction, and executive function of BDD patients, as well as the feasibility and acceptability of MBCT training. METHOD: Patients with BDD were randomized into an 8-week MBCT group (n = 58) or treatment-as-usual (TAU) control group (n = 58) and were assessed at pre-treatment, post-treatment, and 3-month follow-up. RESULTS: Participants who received MBCT showed greater improvement on self-reported and clinician ratings of BDD symptoms, self-reported emotion dysregulation symptoms and executive function compared with TAU participants. Improvement for executive function tasks was partially supported. In addition, feasibility and acceptability of MBCT training were positive. LIMITATIONS: There is no systematic assessment of the severity of key potential outcome variables associated with BDD. CONCLUSION: MBCT may be a useful intervention for patients with BDD, improving patients' BDD symptoms, emotion dysregulation, and executive functioning.

Appearance-related safety behaviors predict symptoms of body dysmorphic disorder following internet-based treatment.

Recent experimental evidence has found that appearance related safety behaviors (i.e., practices meant to avoid a perceived feared outcome) likely play a crucial role in maintaining symptoms of body dysmorphic disorder (BDD). The present study sought to determine if these behaviors predicted BDD symptom severity following treatment. Participants (N = 50) with BDD were randomized to either eight sessions of interpretation bias modification or progressive muscle relaxation. Both treatments led to reductions in BDD symptom severity and appearance-related safety behaviors, though moderate levels of safety behaviors persisted at both posttreatment and follow-up. Importantly, post-treatment appearance related safety behaviors significantly predicted BDD symptom severity at three-month follow-up. Taken together, the present findings suggest appearance related safety behaviors maintain BDD symptoms following effective computerized treatments and provide further evidence for their importance in the treatment of BDD.

Body Dysmorphic Disorder.

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

Mechanisms of cognitive behavioral therapy vs. supportive psychotherapy in body dysmorphic disorder: An exploratory mediation analysis.

Body dysmorphic disorder (BDD) is common, severe, and often chronic. Cognitive behavioral therapy (CBT) is the first-line psychosocial treatment for BDD, with well-established efficacy. However, some patients do not improve with CBT, and little is known about how CBT confers its effects. Neurocognitive processes have been implicated in the etiology and maintenance of BDD and are targeted by CBT-BDD treatment components. Yet, the malleability of these factors in BDD, and their potential role in mediating symptom improvement, are not well understood. Understanding how treatment works could help optimize treatment outcomes. In this secondary data analysis of a randomized clinical trial of CBT vs. supportive psychotherapy (SPT) in BDD (n = 120), we examined whether treatment-related changes in detail processing (Rey-Osterrieth Complex Figure test), maladaptive appearance beliefs (Appearance Schemas Inventory-Revised), and emotion recognition (Emotion Recognition Task) mediated treatment outcome. All constructs improved over time and were associated with symptom improvement. CBT was associated with greater improvements in maladaptive beliefs than SPT. None of the variables examined mediated symptom improvement. Findings suggest that with successful treatment, individuals with BDD demonstrate reduced neurocognitive deficits (detail processing, emotion recognition, maladaptive beliefs) and that CBT is more likely than SPT to improve maladaptive appearance beliefs. More work is needed to understand mechanisms of change and thus maximize treatment outcomes.

Efficacy of Cognitive Therapy for Body Dysmorphic Disorder: A Randomized Controlled Pilot Trial.

Dysfunctional cognitive processes and maladaptive interpersonal patterns have been postulated to maintain body dysmorphic disorder (BDD). The present trial evaluated CT for BDD (CT-BDD), which includes modules targeting maladaptive cognitive processing in BDD, as well as elements of schema therapy related to interpersonal problems. We investigated whether (a) CT-BDD is effective, as compared with a wait-list (WL) group at Week 12; (b) outcome of CT-BDD is maintained at posttreatment and 3- and 6-months follow-up; and (c) whether changes in shame and insight mediate changes in BDD symptom severity. Forty adults with BDD were randomized to 36 weeks immediate CT-BDD (n = 21), or to 12-week WL (n = 19). At Week 12, immediate CT-BDD was significantly superior to WL in clinician-rated BDD symptom severity, insight, self-reported BDD symptoms, shame, depression, general symptomatology, and life satisfaction. Changes in outcomes were associated with moderate to large effect sizes at Week 12. Reductions in shame and increase in insight separately mediated changes in BDD symptom severity during treatment at Week 12. From baseline to posttreatment, significant improvements occurred within CT-BDD in clinician-rated symptom severity, insight, depression, global functioning, self-reported BDD symptoms, shame, depression, general symptomatology, and life satisfaction. At posttreatment, improvements were associated with large effect sizes and were maintained at 3- and 6-month follow-up. Preliminary results support the efficacy of CT-BDD. Addressing interpersonal problems in addition to cognitive dysfunctions may increase the benefit of CBT for BDD patients.

Editorial Perspective: Medical body modification in youth with gender dysphoria or body dysmorphic disorder - is current practice coherent and evidence-based?

In recent decades, there has been a steady increase in the number of people, including adolescents, undergoing medical body modification (MBM) to alter their physically healthy bodies in invasive and nearly irreversible ways through medical treatment (e.g. surgery). While MBM is often recommended for youth with persisting gender dysphoria (GD), in body dysmorphic disorder (BDD) it has been considered contraindicated. Here, we outline the current controversies surrounding MBM practice and recommendations in adolescents with GD versus those with BDD in order to better understand under what circumstances we may or may not support adolescents who want to change their bodies medically and often irreversibly. We compare the two disorders in terms of the overlap and uniqueness of their behavioural and psychological features. In doing so, we discuss limitations of the existing (often low-quality) evidence for and against MBM in young patients. We conclude that the currently available evidence is too preliminary and far from conclusive to make any robust recommendations in terms of benefits and harms of MBM in youth with persisting GD or BDD. However, we strongly recommend further urgent scientific discussions and systematic research efforts into more robust evaluations and the identification of more precise psychological characteristics that may serve as decision criteria for or against MBM - particularly in those adolescents who did not respond to non-MBM, that is, psychiatric/psychological treatment and psychosocial support, if available at all. This will greatly benefit youth healthcare professionals in their challenging clinical practice of making decisions regarding MBM today and in the future.

Acceptance and Compassion-Based Therapy Targeting Shame in Body Dysmorphic Disorder: A Multiple Baseline Study.

Shame is considered central in body dysmorphic disorder (BDD) and empirical accounts highlight the link between shame and BDD symptoms as well as common negative psychosocial effects of the disorder, yet there is a lack of interventions addressing shame in this context. In the past decade, Acceptance and commitment therapy (ACT) and interventions that foster self-compassion have shown promise for reducing the negative effects of shame in a range of clinical problems. The aim of the present study was to develop and evaluate an acceptance and compassion-based treatment specifically targeting shame in BDD. Using a randomized nonconcurrent multiple baseline design, the 12-session intervention, ACT with Compassion (ACTwC), was examined in a psychiatric outpatient sample of five adults diagnosed with BDD. The daily ratings showed marked reductions in BDD-behaviors and self-criticism at posttreatment for four of five participants, while three participants demonstrated decreases in body shame compared to baseline. Improvements were maintained at 6-months follow-up. The intervention also led to reliable long-term improvements in general shame, overall BDD-symptoms, depressive symptoms, and quality of life for four of five participants. All treatment responders showed significant gains in psychological flexibility and self-compassion. Participants reported high credibility and satisfaction with the treatment. These preliminary results suggest that ACTwC may be a promising approach to treating shame in BDD, worthy of further investigation.

Understanding and treating body dysmorphic disorder.

Body dysmorphic disorder (BDD) is a mental disorder that involves a distressing preoccupation with a perceived defect in physical appearance, associated with excessive or repetitive behaviours or mental acts aimed at camouflaging, checking or 'improving' the perceived area of concern. BDD is relatively common, affecting at least 2% of the population world-wide, yet is poorly understood. Professor Susan Rossell has produced a substantial body of influential research, which has improved our understanding of BDD. This includes a more comprehensive understanding of the phenomenology, neurocognition and neurobiology, as well as significant treatment advances. This work will be reviewed in this commentary.