William Menard

Clinical features of body dysmorphic disorder in adolescents and adults

Body dysmorphic disorder (BDD) usually begins during adolescence, but its clinical features have received little investigation in this age group. Two hundred individuals with BDD (36 adolescents; 164 adults) completed interviewer-administered and self-report measures. Adolescents were preoccupied with numerous aspects of their appearance, most often their skin, hair, and stomach. Among the adolescents, 94.3% reported moderate, severe, or extreme distress due to BDD, 80.6% had a history of suicidal ideation, and 44.4% had attempted suicide. Adolescents experienced high rates and levels of impairment in school, work, and other aspects of psychosocial functioning. Adolescents and adults were comparable on most variables, although adolescents had significantly more delusional BDD beliefs and a higher lifetime rate of suicide attempts. Thus, adolescents with BDD have high levels of distress and rates of functional impairment, suicidal ideation, and suicide attempts. BDDs clinical features in adolescents appear largely similar to those in adults.

Age at onset and clinical correlates in body dysmorphic disorder.

OBJECTIVE Age at onset is an important clinical feature of all disorders. However, no prior studies have focused on this important construct in body dysmorphic disorder (BDD). In addition, across a number of psychiatric disorders, early age at disorder onset is associated with greater illness severity and greater comorbidity with other disorders. However, clinical correlates of age at onset have not been previously studied in BDD. METHODS Age at onset and other variables of interest were assessed in two samples of adults with DSM-IV BDD; sample 1 consisted of 184 adult participants in a study of the course of BDD, and sample 2 consisted of 244 adults seeking consultation or treatment for BDD. Reliable and valid measures were used. Subjects with early-onset BDD (age 17 or younger) were compared to those with late-onset BDD. RESULTS BDD had a mean age at onset of 16.7 (SD=7.3) in sample 1 and 16.7 (SD=7.2) in sample 2. 66.3% of subjects in sample 1 and 67.2% in sample 2 had BDD onset before age 18. A higher proportion of females had early-onset BDD in sample 1 but not in sample 2. On one of three measures in sample 1, those with early-onset BDD currently had more severe BDD symptoms. Individuals with early-onset BDD were more likely to have attempted suicide in both samples and to have attempted suicide due to BDD in sample 2. Early age at BDD onset was associated with a history of physical violence due to BDD and psychiatric hospitalization in sample 2. Those with early-onset BDD were more likely to report a gradual onset of BDD than those with late-onset in both samples. Participants with early-onset BDD had a greater number of lifetime comorbid disorders on both Axis I and Axis II in sample 1 but not in sample 2. More specifically, those with early-onset BDD were more likely to have a lifetime eating disorder (anorexia nervosa or bulimia nervosa) in both samples, a lifetime substance use disorder (both alcohol and non-alcohol) and borderline personality disorder in sample 1, and a lifetime anxiety disorder and social phobia in sample 2. CONCLUSIONS BDD usually began during childhood or adolescence. Early onset was associated with gradual onset, a lifetime history of attempted suicide, and greater comorbidity in both samples. Other clinical features reflecting greater morbidity were also more common in the early-onset group, although these findings were not consistent across the two samples.

Surgical and minimally invasive cosmetic procedures among persons with body dysmorphic disorder.

Persons with body dysmorphic disorder (BDD) frequently seek surgical and minimally invasive (MI) treatments to improve their appearance, but few studies have evaluated patient characteristics and outcomes. Surgical/MI treatment histories of 200 persons with BDD were cross-sectionally/retrospectively evaluated. Clinical and demographic characteristics of persons who received such treatments (n = 42) were compared to those who had not (n = 158). Outcomes and reasons for nonreceipt of requested procedures were examined. Receivers of surgical/MI treatments reported less severe current BDD symptoms and delusionality than persons who did not receive such treatments. Surgical/MI treatments were more likely than other cosmetic procedures to decrease preoccupation with the treated body part; however, overall BDD severity improved with only 2.3% of treatments. Cost and physician refusal were the most common reasons requested treatment was not received. However, physicians were more likely to provide requested surgical/MI treatment than other types of requested cosmetic treatment, despite the poor longer-term outcome.

Tanning in Body Dysmorphic Disorder

Tanning in body dysmorphic disorder (BDD) has not previously been studied. In this study, 200 subjects with BDD were evaluated with measures to examine the prevalence of BDD-related tanning—i.e., darkening ones skin color by direct exposure to sunlight or artificial light which is motivated by a desire to improve a perceived appearance defect (i.e., a BDD concern). We also examined clinical characteristics of individuals who engaged in BDD-related tanning. 25% (95% CI, 19.0%–31.0%) of subjects reported BDD-related tanning. Among tanners, the skin was the most common body area of concern (84.0%). All tanners experienced functional impairment due to BDD, 26% had attempted suicide, and quality of life was markedly poor. 52% of tanners had received dermatologic treatment, which was usually ineffective for BDD symptoms. Tanners were more likely than non-tanners to compulsively pick their skin. In conclusion, tanning—a behavior with well-known health risks—is a relatively frequent BDD-related behavior.

A 4-year prospective observational follow-up study of course and predictors of course in body dysmorphic disorder

BACKGROUND This report prospectively examines the 4-year course, and predictors of course, of body dysmorphic disorder (BDD), a common and often severe disorder. No prior studies have prospectively examined the course of BDD in individuals ascertained for BDD. Method The Longitudinal Interval Follow-Up Evaluation (LIFE) assessed weekly BDD symptoms and treatment received over 4 years for 166 broadly ascertained adults and adolescents with current BDD at intake. Kaplan-Meier life tables were constructed for time to remission and relapse. Full remission was defined as minimal or no BDD symptoms, and partial remission as less than full DSM-IV criteria, for at least 8 consecutive weeks. Full relapse and partial relapse were defined as meeting full BDD criteria for at least 2 consecutive weeks after attaining full or partial remission respectively. Cox proportional hazards regression examined predictors of remission and relapse. RESULTS Over 4 years, the cumulative probability was 0.20 for full remission and 0.55 for full or partial remission from BDD. A lower likelihood of full or partial remission was predicted by more severe BDD symptoms at intake, longer lifetime duration of BDD, and being an adult. Among partially or fully remitted subjects, the cumulative probability was 0.42 for subsequent full relapse and 0.63 for subsequent full or partial relapse. More severe BDD at intake and earlier age at BDD onset predicted full or partial relapse. Eighty-eight percent of subjects received mental health treatment during the follow-up period. CONCLUSIONS In this observational study, BDD tended to be chronic. Several intake variables predicted greater chronicity of BDD.

Predictors of remission from body dysmorphic disorder: a prospective study.

In the first naturalistic, prospective study of the course of body dysmorphic disorder (BDD), we examined predictors of remission in 161 subjects over 1 year of follow-up. Data were obtained on clinical characteristics at the intake interview and weekly BDD symptom severity over 1 year using the Longitudinal Interval Follow-Up Evaluation. More severe BDD at intake, longer BDD duration, and the presence of a comorbid personality disorder predicted a lower likelihood of partial or full remission from BDD. BDD remission was not predicted by gender; race/ethnicity; socioeconomic status; being an adult versus an adolescent; age of BDD onset; delusionality of BDD symptoms; or the presence at intake of major depression, a substance use disorder, social phobia, obsessive compulsive disorder, or an eating disorder. Receipt of mental health treatment or nonmental health treatment (e.g., surgery, dermatologic treatment) during the follow-up year also did not predict remission from BDD.

A comparison of quality of life and psychosocial functioning in obsessive-compulsive disorder and body dysmorphic disorder.

BACKGROUND Obsessive-compulsive disorder (OCD) and body dysmorphic disorder (BDD) are possibly related disorders characterized by poor functioning and quality of life. However, few studies have compared these disorders in these important domains. METHODS We compared functioning and quality of life in 210 OCD subjects, 45 BDD subjects, and 40 subjects with comorbid BDD+OCD using reliable and valid measures. RESULTS OCD and BDD subjects had very poor scores across all measures, with no statistically significant differences between the groups. However, comorbid BDD+OCD subjects had greater impairment than OCD subjects on 11 scales/subscales, which remained significant after controlling for OCD severity. Comorbid BDD+OCD subjects had greater impairment than BDD subjects on 2 scales/subscales, which were no longer significant after controlling for BDD severity, suggesting that BDD severity may have accounted for greater morbidity in the comorbid BDD+OCD group. CONCLUSIONS Functioning and quality of life were poor across all three groups, although individuals with comorbid BDD+OCD had greater impairment on a number of measures. It is important for clinicians to be aware that patients with these disorders--and, in particular, those with comorbid BDD and OCD--tend to have very poor functioning and quality of life across a broad range of domains.

A comparison of insight in body dysmorphic disorder and obsessive–compulsive disorder

Insight/delusionality of beliefs is an important dimension of psychopathology across psychiatric disorders. This construct is of increasing interest in obsessive-compulsive and related disorders, including obsessive-compulsive disorder (OCD) and body dysmorphic disorder (BDD). Even though OCD and BDD are considered closely related, no prior study has compared these disorders across a range of categories of global insight (excellent, good, fair, poor, absent/delusional), and only one study has compared these disorders on individual components of insight. Using the reliable and valid Brown Assessment of Beliefs Scale (BABS), this study examined insight/delusionality of OCD- or BDD-related beliefs in 211 individuals with primary OCD versus 68 individuals with primary BDD. In both disorders, levels of insight spanned the full range, from excellent to absent (i.e., delusional beliefs). However, the distribution of BABS scores across insight categories differed significantly by disorder, with the majority of OCD subjects showing excellent or good insight, and the majority of BDD subjects showing poor or absent insight. Compared to OCD subjects, BDD subjects had significantly poorer insight both overall (total BABS score) and on all individual BABS items. BABS score was significantly correlated with BDD and OCD severity, but in regressions it accounted for only 21% of the variance in OCD and 28% in BDD. In summary, both global insight and its individual components are poorer in BDD than in OCD, which has implications for research and clinical care, as well as understanding of the relationship between these disorders. Disorder severity is associated with but not equivalent to insight/delusionality.

A Prospective Pilot Study of Levetiracetam for Body Dysmorphic Disorder

INTRODUCTION Body dysmorphic disorder (BDD) is an often severe disorder, but few treatment studies have been conducted. OBJECTIVE This pilot study explored the efficacy and safety of the antiepileptic medication levetiracetam for BDD. METHODS Seventeen subjects with Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition BDD participated in a 12-week open-label levetiracetam trial. Subjects were assessed at regular intervals with standard measures. RESULTS In intent-to-treat analyses, scores on the Yale-Brown Obsessive Compulsive Scale Modified for BDD (BDD-YBOCS), the primary outcome measure, decreased from 32.5+/-4.7 at baseline to 21.5+/-11.0 at endpoint (P<.001). Approximately 60% (n=9) of subjects were responders (>30% decrease on the BDD-YBOCS). The mean time to response was 4.6+/-2.8 (range: 2-10) weeks. Scores also significantly improved on the Brown Assessment of Beliefs Scale, the Hamilton Rating Scale for Depression, the Global Assessment of Functioning Scale, and the Social and Occupational Functioning Assessment Scale. Scores did not significantly improve on the Quality of Life Enjoyment and Satisfaction Questionnaire, the Beck Anxiety Inventory, or the Social Phobia Inventory. The mean endpoint dose of levetiracetam was 2,044.1+/-1,065.2 (range: 250-3,000) mg/day, and it was relatively well-tolerated. CONCLUSION Randomized, double-blind placebo-controlled studies of levetiracetam for BDD are needed to confirm these preliminary findings.

Occupational functioning and impairment in adults with body dysmorphic disorder

OBJECTIVE Body dysmorphic disorder (BDD) is relatively common and appears to be associated with marked impairment in psychosocial functioning. Previous reports, however, did not investigate occupational functioning in detail, assess impairment specifically in occupational functioning using standardized measures in a nontreatment seeking sample, or examine correlates of occupational impairment. METHODS Occupational functioning and other clinical variables were assessed in 141 adults with BDD. Measures included the Range of Impaired Functioning Tool and other reliable and valid self-report and interviewer-administered measures. RESULTS Fewer than half of subjects were working full-time, and 22.7% were receiving disability pay. Thirty-nine percent of the sample reported not working in the past month because of psychopathology. Of those subjects who worked in the past month, 79.7% reported impairment in work functioning because of psychopathology. Adults with BDD who were not working because of psychopathology were comparable to subjects who were working in most demographic variables, delusionality of BDD beliefs, and duration of BDD. However, compared to subjects who worked in the past month, those not currently working because of psychopathology had more severe BDD and more chronic BDD. They also were more likely to be male, had less education, and had more severe depressive symptoms, a higher rate of certain comorbid disorders, poorer current social functioning and quality of life, a higher rate of lifetime suicidality, and were more likely to have been psychiatrically hospitalized. CONCLUSIONS A high proportion of individuals with BDD were unable to work because of psychopathology; most who worked reported impairment in occupational functioning. Certain clinical variables, including more severe and chronic BDD, were associated with not working.