Nell Ellison

Efficacy of Cognitive Behaviour Therapy versus Anxiety Management for Body Dysmorphic Disorder: A Randomised Controlled Trial

Background: The evidence base for the efficacy of cognitive behaviour therapy (CBT) for treating body dysmorphic disorder (BDD) is weak. Aims: To determine whether CBT is more effective than anxiety management (AM) in an outpatient setting. Method: This was a single-blind stratified parallel-group randomised controlled trial. The primary endpoint was at 12 weeks, and the Yale-Brown Obsessive Compulsive Scale for BDD (BDD-YBOCS) was the primary outcome measure. Secondary measures for BDD included the Brown Assessment of Beliefs Scale (BABS), the Appearance Anxiety Inventory (AAI) and the Body Image Quality of Life Inventory (BIQLI). The outcome measures were collected at baseline and week 12. The CBT group, unlike the AM group, had 4 further weekly sessions that were analysed for their added value. Both groups then completed measures at their 1-month follow-up. Forty-six participants with a DSM-IV diagnosis of BDD, including those with delusional BDD, were randomly allocated to either CBT or AM. Results: At 12 weeks, CBT was found to be significantly superior to AM on the BDD-YBOCS [β = -7.19; SE (β) = 2.61; p < 0.01; 95% CI = -12.31 to -2.07; d = 0.99] as well as the secondary outcome measures of the BABS, AAI and BIQLI. Further benefits occurred by week 16 within the CBT group. There were no differences in outcome for those with delusional BDD or depression. Conclusions: CBT is an effective intervention for people with BDD even with delusional beliefs or depression and is more effective than AM over 12 weeks.

Psychological characteristics and motivation of women seeking labiaplasty.

BACKGROUND Labiaplasty is an increasingly popular surgical intervention but little is known about the characteristics and motivation of women who seek the procedure or the psychosexual outcome. METHOD A total of 55 women seeking labiaplasty were compared with 70 women who did not desire labiaplasty. Various general measures of psychopathology as well as specific measures (Genital Appearance Satisfaction; Cosmetic Procedure Screening for labiaplasty) were used. Labia measurements of the women seeking labiaplasty were also obtained. RESULTS Women seeking labiaplasty did not differ from controls on measures of depression or anxiety. They did, however, express increased dissatisfaction towards the appearance of their genitalia, with lower overall sexual satisfaction and a poorer quality of life in terms of body image. Women seeking labiaplasty reported a significantly greater frequency of avoidance behaviours on all the domains assessed, and greater frequency of safety-seeking behaviours for most of the domains. Key motivations reported for labiaplasty were categorized as cosmetic, functional or sexual. Of the 55 women seeking labiaplasty, 10 met diagnostic criteria for body dysmorphic disorder. CONCLUSIONS This is the first controlled study to describe some of the characteristics and motivations of women seeking labiaplasty. We identified a wide range of avoidance and safety-seeking behaviours, which occurred more frequently in the labiaplasty group than the control group. These could be used clinically as part of a psychological intervention for women seeking labiaplasty.

Development of a Cosmetic Procedure Screening Questionnaire (COPS) for Body Dysmorphic Disorder

Background: Practitioners in a cosmetic setting need a screening questionnaire to identify people with Body Dysmorphic Disorder (BDD). Method: Two groups who desired a cosmetic procedure completed the Cosmetic Procedure Screening Questionnaire (COPS): (a) a group diagnosed with BDD (n =97) and (b) a community control group (n=108). Both groups desired a cosmetic procedure. Item characteristics, reliability and factorial structure were analysed. Convergent validity with selected questionnaires was determined. Sensitivity to change during cognitive behaviour therapy was also determined in a sub-sample of BDD patients. Results: The most sensitive items discriminating between the two groups were used to form the final questionnaire. Receiver Operating Characteristics analysis was used to assess sensitivity and specificity of the COPS to discriminate between the groups and a cut-off score of 40 was chosen. Conclusions: The COPS is a sensitive and specific screening measure for BDD that can be used in cosmetic settings and as a potential research tool to predict dissatisfaction or changes in BDD symptoms after any treatment. Background: Guidelines recommend screening patients for Body Dysmorphic Disorder (BDD) prior to cosmetic surgery to identify those who may require further psychological assessment 1 but there are few validated instruments available. The aim of the current study was therefore to develop a screening questionnaire that (a) was brief, free to download and could identify people with BDD, (b) might predict either dissatisfaction with a cosmetic procedure or no change or deterioration in symptoms of BDD, and (c) may be sensitive to change after an intervention. The new scale was informed by the diagnostic criteria, expert opinion and a previous study that compared patients satisfied with cosmetic rhinoplasty with BDD patients who craved rhinoplasty but had not been able to obtain it . Method: Two groups of participants were recruited: a) Community group We recruited a community group of both genders who were either planning or very motivated to have a cosmetic procedure in the future. The questionnaire was completed by n=108 participants. b) BDD group A psychiatrist conducted an interview based on DSM-IV to diagnose BDD in a clinical setting. Ninety-seven patients with BDD seeking a cosmetic procedure were recruited. All participants completed the following: 1) Cosmetic Procedure Screening (COPS) questionnaire The questionnaire asks for the feature(s) that the person finds unattractive, the nature of the cosmetic procedures they are seeking and diagnostic criteria of BDD. The final version of COPS questionnaire comprises 9 items. Items are scored from 0 (least impaired) to 8 (most impaired). The scale and a full version of this paper is available to download from: http://www.iop.kcl.ac.uk/cadatquestionnaire. The score is achieved by summing Q 2-10. Items 2, 3 and 5 are reversed. The total ranges from 0 to 72 with a higher score reflecting greater impairment. 2) Hospital Anxiety and Depression Scale (HAD) 3) Body Image Quality of Life Inventory (BIQLI) 4) Body Image Disturbance Questionnaire (BIDQ) Results Items on the COPS that showed a significant difference between the two groups, which did not have a significant group x sex interaction and had an effect size (Cohen’s d) of at least 0.80 were retained in the item discriminatory analysis. Nine items met these criteria and were used to form the final questionnaire (see Table 1). Internal Consistency Reliability analysis resulted in an internal consistency of Cronbach’s α = 0.91 with corrected item total ranging from 0.41 to 0.86. Test-retest Reliability 67 participants in the community group repeated the COPS after 1 week. The COPS had good test–retest reliability (r = 0.87, p< 0.01). First administration (M=27.94, SD=13.89), second administration (M=30.71, SD=14.04). Convergent validity Based on the data from both groups the COPS correlated highly with the HAD depression subscale (r = 0.7, p< 0.01) and anxiety subscale (r = 0.66, p< 0.01). COPS also correlated highly with the BIQLI (r = 0.68, p<0.01). Thus higher scores on COPS are associated with lower body image quality of life. Cut-off value and ROC analysis Figure 1 represents the ROC curve for BDD patients compared with community controls. The area under the curve (AUC) for this analysis was .905 (95% CI = .862 .948) indicating that the COPS is an accurate diagnostic test. Based on the discrimination of BDD patients from the community group, a cut-off value of ≥ 40 resulted in a maximal kappa coefficient (k = 0.69, p<0.001). On the basis of this cutoff value, 88.9% of BDD patients and 80.6% of the community group were classified correctly. Sensitivity to change We examined sensitivity to change in a sub-sample of 5 patients with BDD who were undergoing cognitive behaviour therapy . Scores on the COPS were examined at baseline, 6 weeks, and 12 weeks. The mean and SD on the 9-item COPS was 52.40 (SD= 16.70) at baseline and 35.00 (SD= 22.88) at 12 weeks. A one-way repeated measures ANOVA was conducted to compare scores across these 3 treatment points. There was a significant effect across the 3 treatment points [F (1.10, 4.38)= 7.35, p = .047]. Discussion We have developed a brief (nine item) screening questionnaire (COPS) that can be used in a cosmetic procedure setting to screen patients with BDD. The scale has acceptable internal consistency, test-retest reliability, and convergent validity. It has a high sensitivity for the diagnosis of BDD in people who are likely to seek a cosmetic procedure. Individuals who score 40 or more should be referred for further assessment. The COPS was also sensitive to change in patients receiving cognitive behaviour therapy . It may therefore be used an outcome measure after any treatment (including cosmetic procedures) to determine (a) if there is any improvement in symptoms of BDD on a continuous dimension (b) whether it may predict persistence of symptoms or dissatisfaction with a cosmetic procedure (in the absence of any surgical complications). Conflict of interest: None Funding: None Ethical Approval: Brighton and Sussex Ethics Committee Acknowledgements: David Veale and Nell Ellison are supported by the National Institute for Health Research (NIHR) Specialist Biomedical Research Centre for Mental Health award to the South London and Maudsley NHS Foundation Trust and the Institute of Psychiatry, Kings College London. References: 1. National Institute of Clinical Excellence (NICE). Obsessive-compulsive disorder: core interventions in the treatment of obsessive-compulsive disorder and body dysmorphic disorder. Clinical Guideline 31, 2005. 2. Veale D, De Haro L, Lambrou C. Cosmetic rhinoplasty in body dysmorphic disorder. British Journal of Plastic Surgery 2003; 56: 546-551. 3. Veale, D., & Neziroglu, F. (2010). Body Dysmorphic Disorder: a treatment manual. Chichester: John Wiley & Sons. 4. Veale D, Gournay K, Dryden W, Boocock A, Shah F, Willson R, et al. Body dysmorphic disorder: A cognitive behavioural model and pilot randomised controlled trial. Behaviour Research and Therapy 1996; 34: 717-729. Figure 1. Receiver operating characteristics plot of COPS scores of BDD patients compared with community controls.

The Appearance Anxiety Inventory: Validation of a Process Measure in the Treatment of Body Dysmorphic Disorder

BACKGROUND At present there are no measures to identify the cognitive processes and behaviours that might mediate the outcome of treatment in people with Body Dysmorphic Disorder (BDD). AIMS To develop and validate a process measure that can be used to assess the progress of patients throughout therapy and in research for BDD. METHOD The psychometric properties of the Appearance Anxiety Inventory (AAI) were explored in a clinical group of participants diagnosed with BDD (Study 1) and in a non-clinical community group with high appearance concerns (Study 2). Item characteristics, reliability, and factor structure were analysed. Convergent validity with measures of related symptoms was assessed. RESULTS The AAI was found to have good test-retest reliability and convergent validity in the measurement of appearance anxiety. It was also sensitive to change during treatment. The scale was found to have a two-factor structure in the clinical group, with one factor characterized by avoidance, and a second factor comprised of threat monitoring. However, in the community sample it appeared to have a one-factor structure. CONCLUSION The results suggest that the AAI has the psychometric properties to determine whether changes in cognitive processes and behaviours can mediate the outcome following treatment in patients with BDD. This supports its potential usefulness in clinical and research settings.

Validation of genital appearance satisfaction scale and the cosmetic procedure screening scale for women seeking labiaplasty

Abstract Background: Existing outcome studies on women seeking labiaplasty have not used a validated scale that is specific for satisfaction with genital appearance. They have also not screened for the presence of body dysmorphic disorder (BDD). There are therefore two primary aims of this study (1) to validate the Genital Appearance Satisfaction (GAS) scale in women seeking labiaplasty and (2) to modify and validate a version of the Cosmetic Procedures Screening questionnaire (COPS-L), which has previously been used to screen for BDD. Method: Two groups of women were recruited: a group desiring labiaplasty and a control group. All participants completed the GAS, the COPS-L and other general measures of mood, disgust sensitivity, sexual satisfaction and body image quality of life. Results: Both the GAS and COPS-L demonstrated good internal consistency, concurrent and convergent validity with measures of related constructs, and discriminated between women seeking labiaplasty and controls. Three factors were identified in the GAS but were not robust enough to recommend their use clinically as subscales. The COPS-L discriminated between women seeking labiaplasty with and without BDD. Discussion: We recommend that both the GAS and the COPS-L be routinely used for audit and outcome monitoring of interventions for women distressed by the appearance or function of their genitalia. The GAS has an advantage in assessing additional functional symptoms in such women. The COPS-L may be helpful in identifying women with BDD.

A comparison of risk factors for women seeking labiaplasty compared to those not seeking labiaplasty

Little is known about the factors associated with the desire for labiaplasty. We compared 55 women seeking labiaplasty with 70 women in a comparison group who were not seeking labiaplasty. Measures administered included the Perception of Appearance and Competency Related Teasing Scale, Childhood Trauma Questionnaire, Disgust Scale Revised, and the Genital Appearance Satisfaction scale with open-ended questions about their genitalia. Approximately a third of the labiaplasty group recalled specific negative comments in the past towards their labia, a proportion significantly greater than the three per cent in the comparison group. Participants reporting genital teasing also showed higher Genital Appearance Satisfaction scores than those who were not teased. However, women seeking labiaplasty were, compared to the comparison group, no more likely to have a history of neglect or abuse during childhood. There was no difference between the groups on disgust sensitivity or the perception of being teased in the past about their competence or appearance in general.

Abnormal Eating Behaviour in People with a Specific Phobia of Vomiting (Emetophobia)

OBJECTIVE The aim of this study was to explore the eating behaviour in people with a specific phobia of vomiting (SPOV), and whether those identified as restricting their food had a greater degree of psychopathology and impairment than those who do not restrict their food. METHOD We recruited 94 participants with SPOV. They were divided into those who reported restricting their food (SPOV-R) (n = 32) because of fear of vomiting and those who did not restrict their food (SPOV-NR) (n = 62). RESULTS People with SPOV frequently have abnormal eating behaviours to reduce the perceived risk of vomiting. Only 3.7% had a body mass index (BMI) of less than 17.5, and 8.5% had a BMI of less than 18.5. The SPOV-R group had significantly higher frequency of psychopathology and abnormal eating behaviours than the SPOV-NR group. DISCUSSION Abnormal eating behaviour, BMI, and the degree of food restriction are important factors in the assessment of SPOV.

The emetophobia questionnaire (EmetQ-13): Psychometric validation of a measure of specific phobia of vomiting (emetophobia)

This study reports on the development and psychometric evaluation of a self-report assessment of the severity of symptoms of emetophobia. Using a sample of 95 individuals with emetophobia, and a matched sample of 90 control participants, a 13-items inventory was developed that showed a clear three-factor structure. The EmetQ-13 had good internal consistency (α=.82 in the clinical sample, and α=.85 in the control sample), and one-week test-retest reliability (rxx=.76). The EmetQ-13 showed significant correlations with another measure of emetophobia symptoms, the Specific Phobia of Vomiting Inventory, and related constructs such as disgust sensitivity. The measure showed excellent ability to classify emetophobic and non-emetophobic individuals, with correct assignment in 96.2% of cases. The EmetQ-13 also correlated significantly with a behavioural approach test using a vomit-like stimulus. The initial evaluation of the EmetQ-13 suggests that it is a reliable and valid measure for the assessment of emetophobia.