Practitioner Review: Assessment and treatment of body dysmorphic disorder in young people.

Body dysmorphic disorder (BDD) is a relatively common and highly impairing mental disorder that is strikingly underdiagnosed and undertreated in Child and Adolescent Mental Health Services (CAMHS). The only clinical guidelines for the management of BDD in youth were published nearly 20 years ago, when empirical knowledge was sparse. Fortunately, there has been a surge in research into BDD over the last 10 years, shedding important insights into the phenomenology, epidemiology, assessment and treatment of the disorder in young people. This review aimed to provide an overview of recent research developments of relevance to clinicians and healthcare policymakers. We summarise key findings regarding the epidemiology of BDD in youth, which indicate that the disorder usually develops during teenage years and affects approximately 2% of adolescents at any one point in time. We provide an overview of aetiological research, highlighting that BDD arises from an interplay between genetic and environmental influences. We then focus on screening and assessment strategies, arguing that these are crucial to promote detection and diagnosis of this under-recognised condition. Additionally, we summarise the recommended treatment approaches for BDD in youth, namely cognitive behaviour therapy with or without selective serotonin reuptake inhibitors. The review concludes by highlighting key knowledge gaps and priorities for future research including, but not limited to, better understanding aetiological factors, long-term consequences and treatment.

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.

An Evaluation of a New Autism-Adapted Cognitive Behaviour Therapy Manual for Adolescents with Obsessive-Compulsive Disorder.

Obsessive-compulsive disorder (OCD) and autism spectrum disorder (ASD) frequently co-occur. Standard cognitive behaviour therapy (CBT) for OCD outcomes are poorer in young people with ASD, compared to those without. The aim of this naturalistic study was to evaluate the effectiveness of a novel adolescent autism-adapted CBT manual for OCD in a specialist clinical setting. Additionally, we examined whether treatment gains were maintained at 3-month follow-up. Thirty-four adolescents underwent CBT; at the end of treatment, 51.51% were treatment responders and 21.21% were in remission. At 3-month follow-up, 52.94% were responders and 35.29% remitters. Significant improvements were also observed on a range of secondary measures, including family accommodation and global functioning. This study indicates this adapted package of CBT is associated with significant improvements in OCD outcomes, with superior outcomes to those reported in previous studies. Further investigation of the generalizability of these results, as well as dissemination to different settings, is warranted.

Co-occurring obsessive-compulsive disorder and autism spectrum disorder in young people: prevalence, clinical characteristics and outcomes.

Obsessive-compulsive disorder (OCD) and autism spectrum disorders (ASD) commonly co-occur and are considered challenging to manage when they co-occur in youth. However, clinical characteristics and prognosis of this group remain poorly understood. This study examined the prevalence, clinical correlates and outcomes of paediatric OCD co-occurring with ASD (OCD + ASD) in a large clinical cohort. Data were extracted from electronic clinical records of young people aged 4-17 years who had attended a mental health trust in South London, United Kingdom. We identified young people with diagnoses of OCD + ASD (n = 335), OCD without ASD (n = 1010), and ASD without OCD (n = 6577). 25% of youth with OCD had a diagnosis of ASD, while 5% of those with ASD had a diagnosis of OCD. At diagnosis, youth with OCD + ASD had lower psychosocial functioning scores on the clinician-rated Child Global Assessment Scale (CGAS) compared to those with either OCD or ASD. Youth with OCD + ASD were equally likely to receive CBT compared to those with OCD but were more likely to be prescribed medication and use services for longer than either comparison group. Youth with OCD + ASD showed significant improvements in functioning (CGAS scores) after service utilisation but their gains were smaller than those with OCD. OCD + ASD commonly co-occur, conferring substantial impairment, although OCD may be underdiagnosed in youth with ASD. Young people with co-occurring OCD + ASD can make significant improvements in functioning with routine clinical care but are likely to remain more impaired than typically developing youth with OCD, indicating a need for longer-term support for these young people.

The Work and Social Adjustment Scale, Youth and Parent Versions: Psychometric Evaluation of a Brief Measure of Functional Impairment in Young People.

The Work and Social Adjustment Scale (WSAS) is a brief global measure of functional impairment that is widely used in adult health. We have adapted the WSAS for its use in youth, the WSAS-Youth version (WSAS-Y) and WSAS-Parent version (WSAS-P). This study evaluated the psychometric properties of the scale. The internal consistency, factor structure, convergent and divergent validity, test-retest reliability and sensitivity to change of the WSAS-Y/P were studied in 525 children and adolescents with obsessive-compulsive disorder and related disorders receiving treatment. The internal consistency of the WSAS-Y/P was excellent across diagnostic groups and time-points. Exploratory factor analysis extracted a single-factor of functional impairment, explaining in excess of 85% of the variance. The test-retest reliability was adequate. The WSAS-Y/P correlated more strongly with other measures of functional impairment than with measures of symptom severity, indicating good convergent/divergent validity. Finally, the WSAS-Y/P was highly sensitive to change after treatment.

Innovations in Practice: Body dysmorphic disorder in youth - using the Development and Well-Being Assessment as a tool to improve detection in routine clinical practice.

BACKGROUND: Body Dysmorphic Disorder (BDD) is a distressing disorder that is widely underdetected in youth. This study aimed to examine the potential utility of the Development and Well-Being Assessment (DAWBA) as a tool to improve recognition of BDD in routine clinical practice. METHODS: One hundred and sixty-one patients assessed across two national and specialist child and adolescent mental health services, one specialising in mood disorders and one specialising in obsessive compulsive disorder and BDD, were included in this study. Results from the DAWBA were compared with clinical diagnosis to examine the utility of the DAWBA in detecting BDD. RESULTS: Only 27% of participants who received a diagnosis of BDD at assessment had been referred with concerns about appearance anxiety suggesting significant under detection in youth mental health services. Using the single-screener question on the DAWBA, it was possible to correctly identify 97% of cases with BDD. CONCLUSIONS: Body dysmorphic disorder often goes undetected in routine clinical practice. The DAWBA shows promise as a tool for helping clinicians to accurately detect BDD in routine clinical practice.

Perceived treatment barriers and experiences in the use of services for obsessive-compulsive disorder across different ethnic groups: a thematic analysis.

BACKGROUND: Patients from ethnic minority backgrounds are underrepresented in clinical settings. Factors like cost of treatment, poor knowledge of the health system, geographic availability of services, lack of mental health literacy, differences in health beliefs, and social barriers have been identified as reasons for these inequalities. The aim of this study was to identify and compare barriers that parents from different ethnic groups face when accessing specialist services for obsessive-compulsive disorder (OCD) for their children. METHOD: Ten parents from White backgrounds and 10 from ethnic minority backgrounds were recruited from the National and Specialist OCD, BDD, and Related Disorders Clinic for Young People, London, United Kingdom. They were interviewed about their opinions and experiences when accessing treatment. RESULTS: Using thematic analysis, several common barriers for both groups were identified. These included a lack of knowledge of OCD, lack of resources within the health system, previous negative experiences, lack of trust in the mental health system, lack of time and financial issues, no support out of hours, bullying, and inconvenient location of services. In addition, there were several barriers that were endorsed by ethnic minority groups but not by the parents from White backgrounds, namely stigma and discrimination from within their communities, shame and denial, a general lack of trust in the health system by their cultural group, different beliefs about mental health issues, and discrimination from within the system. CONCLUSIONS: Policy-makers and clinicians should be aware of the additional barriers minority patients may face in accessing treatment and should support interventions designed to overcome them.

Illness perception, help-seeking attitudes, and knowledge related to obsessive-compulsive disorder across different ethnic groups: a community survey.

PURPOSE: Despite similar prevalence rates across ethnicities, ethnic minorities with obsessive-compulsive disorder (OCD) are under-represented in research and clinical settings. The reasons for this disproportion have been sparsely studied. We explored potential differences in illness perception, help-seeking attitudes, illness knowledge, and causal attributions that could help explain the lower uptake of treatment for OCD amongst ethnic minorities. METHODS: Two-hundred and ninety-three parents (139 White British, 61 Black African, 46 Black Caribbean, and 47 Indian) were recruited from the general population in South-East London, UK. Using a text vignette methodology, participants completed a survey including questions on illness perception, help-seeking attitudes, OCD knowledge, and causal attributions. RESULTS: The groups did not differ in socio-demographic characteristics and family history of OCD. White British parents perceived that the OCD difficulties would have more negative impact on their children and that treatment would be more helpful, compared to the ethnic minorities; the largest differences were observed between White British and Indian parents. Ethnic minorities were more prone to say that would seek help from their religious communities. Black African parents were more in favor of not seeking help for the described difficulties and, in general, perceived more treatment barriers. White British parents seemed to be better informed about OCD than ethnic minority parents. CONCLUSIONS: The results offer some plausible explanations for the large inequalities in access to services amongst ethnic minorities with OCD. Clinicians and policy-makers need to be aware of these socio-cultural factors when designing strategies to encourage help-seeking behaviors in these populations.

Modified Cognitive Behavior Therapy for Severe, Treatment-Resistant Obsessive-Compulsive Disorder in an Adolescent With Autism Spectrum Disorder.

There is a high rate of comorbidity between obsessive-compulsive disorder (OCD) and autism spectrum disorders (ASD). Standard cognitive-behavior therapy (CBT) protocols have been shown to be less effective in treating OCD in young people with ASD than in typically developing youth. This case study describes the treatment of an adolescent boy with severe, treatment-resistant OCD and ASD using a modified CBT approach. Modifications to a standard evidence-based CBT for OCD protocol included extended psychoeducation about anxiety; regular home-based sessions; and increased involvement of systems, including family and school. Multi-informant outcome data indicated significant improvements in OCD symptoms over the course of treatment with gains being maintained over a 12-month follow-up period. These findings demonstrate the potential efficacy of modified CBT for pediatric OCD in the context of ASD.

Ethnic inequalities in the use of secondary and tertiary mental health services among patients with obsessive-compulsive disorder.

BACKGROUND: Obsessive-compulsive disorder (OCD) has similar prevalence rates across ethnic groups. However, ethnic minorities are underrepresented in clinical trials of OCD. It is unclear whether this is also the case in clinical services. AIMS: To explore whether ethnic minorities with OCD are underrepresented in secondary and tertiary mental health services in the South London and Maudsley (SLaM) NHS Foundation Trust. METHOD: The ethnic distribution of patients with OCD seen between 1999 and 2013 in SLaM (n = 1528) was compared with that of the general population in the catchment area using census data. A cohort of patients with depression (n = 22 716) was used for comparative purposes. RESULTS: Ethnic minorities with OCD were severely underrepresented across services (-57%, 95% CI -62% to -52%). The magnitude of the observed inequalities was significantly more pronounced than in depression (-29%, 95% CI -31% to -27%). CONCLUSIONS: There is a clear need to understand the reasons behind such ethnic inequalities and implement measures to reduce them.

How resistant is 'treatment-resistant' obsessive-compulsive disorder in youth?

OBJECTIVES: Obsessive-compulsive disorder (OCD) is often perceived as being difficult to treat. This study aimed to test the hypothesis that treatment non-response in routine clinical practice is often due to failures in the delivery of treatment, and that most patients who are apparently treatment-resistant will respond to treatment if adequately delivered. DESIGN: Retrospective cohort data analysis. METHODS: Forty-three young people with severe, treatment-resistant OCD (defined as Children's Yale-Brown Obsessive-Compulsive Scale [CY-BOCS] scores ≥ 30 and non-response to previous cognitive behaviour therapy [CBT] and selective serotonin reuptake inhibitors) were referred to a specialist clinic and completed a course of manualized CBT, with (N = 21) or without (N = 22) optimization of medication. A sub-sample (N = 15) completed a semi-structured interview to determine characteristics of their previous CBT; quality was assessed according to pre-determined criteria. RESULTS: Specialist treatment was associated with significant reductions in OCD symptoms at post-treatment with gains maintained at 3-month follow-up. At the 3-month follow-up, 58% of patients showed a meaningful clinical response (≥ 35% drop on the CY-BOCS) and 22% were in remission (≤ 12 on the CY-BOCS). Patients whose medication was optimized tended (non-significantly) to have better responses. The quality of previous CBT was assessed in a sub-group of participants and rated as inadequate in 95.5% of cases. The most common inadequacy was insufficient focus on exposure techniques. CONCLUSIONS: These findings provide support for the notion that treatment non-response in routine practice may be due to technical treatment failures and highlight the need to disseminate good quality evidence-based treatment among this population. Research is also needed to understand factors that impede outcome to further improve response and remission rates. PRACTITIONER POINTS: Among young people with OCD, failure to respond to treatment in routine clinical practice may often reflect the nature of the treatment received. Exposure techniques may often be overlooked in CBT for OCD, potentially resulting in poor therapeutic response. Most young people with severe and apparent treatment-resistant OCD respond to outpatient CBT incorporating E/RP. Further research is needed to establish effective methods for disseminating good quality CBT for OCD.

Suicidal thoughts and behaviours in body dysmorphic disorder: Prevalence and correlates in a sample of mental health service users in the UK.

BACKGROUND: Previous research indicates an association of body dysmorphic disorder (BDD) with suicidal thoughts and behaviours, but has largely relied on small cohorts drawn from specialist clinics. METHODS: Anonymised health-records from the South London and Maudsley NHS Foundation Trust between 2007 and 2019 were systematically searched using the Clinical Record Interactive Search data system. RESULTS: 298 patients diagnosed with BDD between age 12 and 65 years were identified. 206 (69 %) had experienced lifetime suicidal ideation. 149 (50 %) had recorded lifetime acts of self-harm or suicide attempts, most commonly involving cutting and self-poisoning. Rates of self-harm/suicide attempts were similar in those diagnosed before or after 18 years. Comorbid depression was associated with suicidal ideation (OR: 4.26 95% CI 2.07-9.72). Additionally, comorbid depression, OCD and anxiety were all associated with self-harm/suicide attempts (OR: 1.94 95% CI 1.15-3.31, OR: 1.99 95% CI 1.09-3.73, and OR: 1.93 95% CI 1.09-3.45, respectively). The presence of two or more psychiatric comorbidities was associated with a significantly elevated likelihood of suicidal ideation (OR: 7.06 95% CI 2.80-21.7) and self-harm/suicide attempts (OR: 4.62 95% CI 2.32-9.62). LIMITATIONS: It is likely that BDD was under-diagnosed in the cohort, and those identified may not be representative. Additionally, the frequency and detail with which suicidal thoughts and behaviours were assessed varied and may also represent underestimates. CONCLUSIONS: Suicidal ideation and self-harm/suicide attempts are common among individuals with BDD accessing mental health services. Psychiatric comorbidity and suicidal ideation should be assessed in all BDD patients.

Cognitive behavior therapy for comorbid obsessive-compulsive disorder in high-functioning autism spectrum disorders: a randomized controlled trial.

BACKGROUND: High rates of anxiety disorders, particularly obsessive compulsive disorder (OCD) are reported in people with Autism spectrum disorders (ASD). Group cognitive behavioral treatment (CBT) has been found effective for anxiety in young people with ASD but not been OCD specific. One uncontrolled pilot study of individual CBT for OCD for adults with ASD showed good treatment efficacy. METHODS: Forty-six adolescents and adults (mean age 26.9 years, 35 Males) with ASD and comorbid OCD were randomized to CBT for OCD or anxiety management (AM), a plausible control treatment. Treatments were matched in duration (mean of 17.4 sessions CBT; 14.4 sessions AM), the Yale-Brown Obsessive Compulsive Severity Scale (YBOCS) as primary outcome measure and evaluations blind to treatment group. Treatment response was defined as > 25% reduction in YBOCS total severity scores. RESULTS: Both treatments produced a significant reduction in OCD symptoms, within-group effect sizes of 1.01 CBT group and 0.6 for the AM group. There were no statistically significant differences between the two groups at end of treatment, although more responders in the CBT group (45 versus 20%). Effect sizes for self-rated improvement were small (0.33 CBT group; -0.05 AM group). Mild symptom severity was associated with improvement in the AM but not the CBT group. Family/carer factors were important for both groups, in that increased family accommodation was associated with poorer outcome. CONCLUSIONS: Evidence-based psychological interventions, both AM and CBT, were effective in treating comorbid OCD in young people and adults with ASD.

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.

The association between social media use and body dysmorphic symptoms in young people.

Introduction: Social media use (SMU) is highly prevalent amongst young people and previous research suggests an association with mental health problems, including poor body image. However, the potential relationship between SMU and body dysmorphic disorder (BDD) has received little attention. Furthermore, little is known about the factors that moderate the potential association between SMU and body dysmorphic symptoms. The current study tested the associations between three facets of SMU and body dysmorphic symptoms and explored perfectionism as a moderator in a non-clinical sample. Method: Two-hundred and nine 16-18-year-olds (mean age = 16.5 years, 37% male) recruited from schools in London completed an online survey measuring aspects of SMU, including: frequency of image-and text-based SMU; motivations for SMU (appearance, popularity, connection or values and interests); and active and passive SMU. Participants additionally completed validated measures of body dysmorphic symptoms, perfectionism, and anxiety/depressive symptoms. Linear regression models tested the association of body dysmorphic symptoms with different facets of SMU, with and without adjustment for age, sex and anxiety/depressive symptoms. Results: Frequency of use of image-based, but not text-based, platforms was significantly and positively associated with body dysmorphic symptoms, and this association remained significant in the adjusted models. Appearance-based motivation for SMU was the only motivator uniquely associated with body dysmorphic symptoms across the unadjusted and adjusted models. Passive, not active, SMU was associated with body dysmorphic symptoms in unadjusted models, but this association became non-significant in the adjusted models. Self-oriented perfectionism moderated the association between frequency of image-based SMU and body dysmorphic symptoms. Discussion: Image-based SMU, and appearance-based motivations for SMU, are positively associated with body dysmorphic symptoms. Self-oriented perfectionism may amplify the relationship between SMU and body dysmorphic symptoms. Our findings highlight the importance of a nuanced approach to examining SMU, and the need for further research to determine whether specific facets of SMU contribute to the development and/or maintenance of body dysmorphic symptoms.

Multifamily therapy for young people with OCD: An acceptability and satisfaction study.

Individual cognitive-behavioral therapy (CBT) is the recommended first-line psychological treatment for young people with obsessive-compulsive disorder (OCD), with good outcomes. However, because some young people only partially respond to CBT, it is necessary to improve treatment outcomes. This is the first study to explore the acceptability and satisfaction of a new multifamily therapy (MFT). Three groups were attended by 16 young people with OCD, their parents, and siblings. Parents and young people completed questionnaires and focus groups. Thematic analysis was applied to transcripts of focus groups. The majority of young people and parents (93.9%) were satisfied or very satisfied. Thematic analysis identified benefits, including increased understanding of OCD, support from the group, and a feeling of not being alone. Further research is required to establish the group's effectiveness on OCD symptom severity and to identify the factors that MFT addresses. MFT shows promise as an acceptable and satisfactory treatment.