Ulrike Buhlmann

Augmentation of Behavior Therapy With d -Cycloserine for Obsessive-Compulsive Disorder

OBJECTIVE This study examined whether d-cycloserine, a partial agonist at the N-methyl-D-aspartate (NMDA) glutamatergic receptor, enhances the efficacy of behavior therapy for obsessive-compulsive disorder (OCD). METHOD A randomized, double-blind, placebo-controlled trial investigating D-cycloserine versus placebo augmentation of behavior therapy was conducted in 23 OCD patients. Patients first underwent a diagnostic interview and pretreatment evaluation, followed by a psychoeducational/treatment planning session. Then they received 10 behavior therapy sessions. Treatment sessions were conducted twice per week. One hour before each of the behavior therapy sessions, the participants received either D-cycloserine, 100 mg, or a placebo. RESULTS Relative to the placebo group, the D-cycloserine groups OCD symptoms were significantly more improved at mid-treatment, and the D-cycloserine groups depressive symptoms were significantly more improved at posttreatment. CONCLUSIONS These data provide support for the use of D-cycloserine as an augmentation of behavior therapy for OCD and extend findings in animals and other human disorders suggesting that behavior therapy acts by way of long-term potentiation of glutamatergic pathways and that the effects of behavior therapy are potentiated by an NMDA agonist.

The prevalence of body dysmorphic disorder: a population-based survey

BACKGROUND Body dysmorphic disorder (BDD) is a highly distressing and impairing disorder characterized by a preoccupation with imagined or slight physical defects in appearance. Well designed studies on its prevalence and on base rates for diagnostic criteria are rare. Therefore this study aimed to reveal prevalence rates of BDD in the general population and to examine clinical features associated with BDD. METHOD Of 4152 selected participants 2552, aged 14-99 years, participated in this German nationwide survey. Participants were carefully selected to ensure that the sample was representative; they were visited by a study assistant who provided instructions and help if needed. Participation rate was 62.3%. DSM-IV criteria for BDD, as well as subthreshold features (e.g. individuals who consider some part(s) of their body as ugly or disfigured, but do not fulfill all BDD criteria) were examined. We also assessed suicidal ideation associated with the belief of having an ugly body part, as well as the desire for cosmetic surgery. Furthermore, somatization symptoms were assessed. RESULTS The prevalence of current BDD was 1.7% (CI 1.2-2.1%). Individuals with BDD reported higher rates of suicidal ideation (19% v. 3%) and suicide attempts due to appearance concerns (7% v. 1%) than individuals who did not meet criteria for BDD. Somatization scores were also increased in individuals with BDD, relative to those without. BDD was associated with lower financial income, lower rates of living with a partner, and higher rates of unemployment. CONCLUSIONS Our study shows that self-reported BDD is relatively common and associated with significant morbidity.

Updates on the prevalence of body dysmorphic disorder: A population-based survey

Body dysmorphic disorder (BDD) is characterised by a preoccupation with perceived defects in ones appearance, which leads to significant distress and/or impairment. Although several studies have investigated the prevalence of BDD, many studies have methodological limitations (e.g., small sample sizes and student populations), and studies on the prevalence of BDD in the general population are limited. In the current study, 2510 individuals participated in a representative German nationwide survey. Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) criteria for BDD and associated characteristics such as suicidality and the prevalence of plastic surgeries were examined using self-report questionnaires. The prevalence of current BDD was 1.8% (N=45). Further, individuals with BDD, relative to individuals without BDD, reported significantly more often a history of cosmetic surgery (15.6% vs. 3.0%), higher rates of suicidal ideation (31.0% vs. 3.5%) and suicide attempts due to appearance concerns (22.2% vs. 2.1%). The current findings are consistent with previous findings, indicating that self-reported BDD is a common disorder associated with significant morbidity.

Characteristics of memory dysfunction in body dysmorphic disorder

Although body dysmorphic disorder (BDD) is receiving increasing empirical attention, very little is known about neuropsychological deficits in this disorder. The current study investigated the nature of memory dysfunction in BDD, including the relationship between encoding strategies and verbal and nonverbal memory performance. We evaluated 17 patients with BDD and 17 healthy controls using the Rey-Osterrieth Complex Figure Test (RCFT) and the California Verbal Learning Test (CVLT). BDD patients differed significantly from healthy controls on verbal and nonverbal learning and memory indices. Multiple regression analyses revealed that group differences in free recall were statistically mediated by deficits in organizational strategies in the BDD cohort. These findings are similar to patterns previously observed in obsessive-compulsive disorder (OCD), suggesting a potential relationship between OCD and BDD. Studies in both groups have shown that verbal and nonverbal memory deficits are affected by impaired strategic processing.

Emotion recognition deficits in body dysmorphic disorder

Patients with Body Dysmorphic Disorder (BDD) are characterized by excessive concerns about imagined defects in their appearance, most commonly, facial features. In this study, we investigated (1) the ability to identify facial expressions of emotion, and (2) to discriminate single facial features in BDD patients, Obsessive-Compulsive Disorder (OCD) patients, and in healthy control participants. Specifically, their ability for general facial feature discrimination was assessed using the Short Form of the Benton Facial Recognition Test (Benton AL, Hamsher KdeS, Varney NR, Spreen O. Contributions to neuropsychological assessment: a clinical manual. New York: Oxford University Press; 1983). However, findings of the BFRT indicate no differences among the groups. Moreover, participants were presented with facial photographs from the Ekman and Friesen (Ekman P, Friesen W. Unmasking the face: a guide to recognizing emotions from facial cues. Englewood Cliffs, NJ: Prentice-Hall; 1975 and Ekman P, Friesen W. Pictures of facial affect. Palo Alto: Consulting Psychologists Press, 1976) series and were asked to identify the corresponding emotion. The BDD group was less accurate than the control group, but not the OCD group, in identifying facial expressions of emotion. Relative to the control and OCD groups, the BDD group more often misidentified emotional expressions as angry. In contrast to the findings of Sprengelmeyer et al. [Proc. Royal Soc. London Series B: Biol. Sci. 264 (1997),1767], OCD patients did not show a disgust recognition deficit. Poor insight and ideas of reference, common in BDD, might partly result from an emotion recognition bias for angry expressions. Perceiving others as angry and rejecting might reinforce concerns about ones personal ugliness and social desirability.

Need for speed: Evaluating slopes of OCD recovery in behavior therapy enhanced with d-cycloserine

Evidence suggests that the antibiotic d-cycloserine (DCS) enhances the treatment effects of exposure and response prevention (ERP) for Obsessive-Compulsive Disorder (OCD). Further, evidence suggests that the effects of DCS diminish partway through treatment, but it is unclear to what extent. In an effort to evaluate these issues, the current study re-analyzes data from a 10-session randomized controlled trial of ERP+DCS versus ERP+placebo in a sample of 22 adults with OCD. We analyzed repeated-measures mixed models with random slopes and intercepts across different intervals: sessions 1-10, 1-5, and 6-10. The results indicate that the course of ERP was 2.3 times faster over the full 10 sessions for the DCS compared to the placebo group, and nearly six times quicker in the first half of ERP. Further interpretation of the results suggests that DCS does not amplify the effects of ERP, but instead initiates treatment effects sooner in treatment. In addition, DCS does not necessarily lose its effect over repeated use, but instead may exhaust its maximum utility after effectively jump-starting ERP. Ultimately, DCS may provide a means for curtailing treatment costs, decreasing treatment dropout and refusal rates, and enhancing access to care.

Interpretive biases for ambiguous information in body dysmorphic disorder.

Anxiety-disordered patients and individuals with high trait anxiety tend to interpret ambiguous information as threatening. The purpose of this study was to investigate whether interpretive biases would also occur in body dysmorphic disorder (BDD), which is characterized by a preoccupation with imagined defects in ones appearance. We tested whether BDD participants, compared with obsessive-compulsive disorder participants and healthy controls, would choose threatening interpretations for ambiguous body-related, ambiguous social, and general scenarios. As we hypothesized, BDD participants exhibited a negative interpretive bias for body-related scenarios and for social scenarios, whereas the other groups did not. Moreover, both clinical groups exhibited a negative interpretive bias for general scenarios.

Selective processing of emotional information in body dysmorphic disorder.

Body dysmorphic disorder (BDD) is a syndrome characterized by distress about imagined defects in ones appearance. Though categorized as a somatoform disorder, BDD is marked by many characteristics associated with social phobia (e.g., fear of negative evaluation) and obsessive-compulsive disorder (e.g., intrusive thoughts about ones ugliness, checking). In the present experiment, we tested whether BDD patients exhibit selective processing of threat in the emotional Stroop paradigm as do anxiety-disordered patients. Relative to healthy control participants, BDD patients exhibited greater Stroop interference for positive and negative words, regardless of disorder-relevance, than for neutral words. Further analyses suggested that interference tended to be greatest for positive words related to BDD. These data suggest that BDD patients are vulnerable to distraction by emotional cues in general, and by words related to their current concerns in particular. Results suggest that BDD may indeed be related to anxiety disorders such as social phobia.

Modular Cognitive-Behavioral Therapy for Body Dysmorphic Disorder: A Randomized Controlled Trial

There are few effective treatments for body dysmorphic disorder (BDD) and a pressing need to develop such treatments. We examined the feasibility, acceptability, and efficacy of a manualized modular cognitive-behavioral therapy for BDD (CBT-BDD). CBT-BDD utilizes core elements relevant to all BDD patients (e.g., exposure, response prevention, perceptual retraining) and optional modules to address specific symptoms (e.g., surgery seeking). Thirty-six adults with BDD were randomized to 22 sessions of immediate individual CBT-BDD over 24 weeks (n=17) or to a 12-week waitlist (n=19). The Yale-Brown Obsessive-Compulsive Scale Modified for BDD (BDD-YBOCS), Brown Assessment of Beliefs Scale, and Beck Depression Inventory-II were completed pretreatment, monthly, posttreatment, and at 3- and 6-month follow-up. The Sheehan Disability Scale and Client Satisfaction Inventory (CSI) were also administered. Response to treatment was defined as ≥30% reduction in BDD-YBOCS total from baseline. By week 12, 50% of participants receiving immediate CBT-BDD achieved response versus 12% of waitlisted participants (p=0.026). By posttreatment, 81% of all participants (immediate CBT-BDD plus waitlisted patients subsequently treated with CBT-BDD) met responder criteria. While no significant group differences in BDD symptom reduction emerged by Week 12, by posttreatment CBT-BDD resulted in significant decreases in BDD-YBOCS total over time (d=2.1, p<0.0001), with gains maintained during follow-up. Depression, insight, and disability also significantly improved. Patient satisfaction was high, with a mean CSI score of 87.3% (SD=12.8%) at posttreatment. CBT-BDD appears to be a feasible, acceptable, and efficacious treatment that warrants more rigorous investigation.

Effectiveness of Cognitive Therapy for Obsessive-Compulsive Disorder: An Open Trial

This study examined the effectiveness of a new type of purely Beckian cognitive treatment for Obsessive-Compulsive Disorder (OCD). The manualized treatment used a flexible format permitting therapists to choose among several modules developed to address specific OCD belief domains identified by the Obsessive-Compulsive Cognition Working Group (1997). Fifteen participants diagnosed with OCD were treated individually for 14 weekly sessions. Ten participants had never received behavior therapy, and 5 participants had failed to benefit from exposure and response prevention (ERP) in the past. Participants improved with respect to their depressive and obsessive-compulsive symptoms over the course of the treatment. However, those who had never received ERP improved more than those who had failed to benefit from prior ERP. Implications of the study are discussed.