The nature and functions of appearance-related comparisons in body dysmorphic disorder.

Appearance-related comparisons (A-RCs) in body dysmorphic disorder (BDD) are under researched despite their probable role in disorder maintenance. The present study therefore aimed to explore the nature (frequency, direction and automaticity), and functions of A-RCs in BDD. N = 43 including people with BDD (n = 23) and controls (n = 20) matched approximately on age and sex were recruited. A mixture of standardized and devised questionnaires on body image and A-RCs were completed. A-RCs were significantly more frequent, generally more upward (to more attractive standards of comparison), and more automatic in people with BDD relative to the control group. People with BDD also held significantly stronger agreement with beliefs about A-RCs as serving functions of: self-evaluation, self-improvement, self-enhancement, and in particular, self-loathing (a way to confirm beliefs about physical unattractiveness) and social threat management. This research presents evidence that the nature and functions of A-RCs in BDD have a role in this disorder's maintenance. Clinical implications, limitations, and future directions for research are discussed.

"We make something with the flower, but feel like I make with myself something": The role of a community arts project supporting women who have experienced human trafficking.

Human trafficking can have multiple adverse effects on a victim's mental and physical health. The study explored how a small UK community arts project was experienced by individuals post-trafficking and the impact it had on well-being. Community-based participatory research was employed to increase understanding the experiences of six female participants taking part in a community arts project. Data were analyzed using thematic analysis. Themes of Authentic Care, Building Confidence, and Creative Expression were developed. Findings suggest the community arts organization played a vital role in supporting women to build trust and social connections, as well as to feel valued. Artistic activities helped participants express individuality, had therapeutic benefits, and provided motivation, routine, and space from worries. The role of community arts organizations is important in supporting individuals in the context of limited post-trafficking services.

Long-Term Outcomes of Cognitive-Behavioral Therapy for Adolescent Body Dysmorphic Disorder.

Emerging evidence suggests that cognitive-behavioral therapy (CBT) is an efficacious treatment for adolescent body dysmorphic disorder (BDD) in the short term, but longer-term outcomes remain unknown. The current study aimed to follow up a group of adolescents who had originally participated in a randomized controlled trial of CBT for BDD to determine whether treatment gains were maintained. Twenty-six adolescents (mean age = 16.2, SD = 1.6) with a primary diagnosis of BDD received a course of developmentally tailored CBT and were followed up over 12 months. Participants were assessed at baseline, midtreatment, posttreatment, 2-, 6-, and 12-month follow-up. The primary outcome measure was the clinician-rated Yale-Brown Obsessive-Compulsive Scale Modified for BDD. Secondary outcomes included measures of insight, depression, quality of life, and global functioning. BDD symptoms decreased significantly from pre- to posttreatment and remained stable over the 12-month follow-up. At this time point, 50% of participants were classified as responders and 23% as remitters. Participants remained significantly improved on all secondary outcomes at 12-month follow-up. Neither baseline insight nor baseline depression predicted long-term outcomes. The positive effects of CBT appear to be durable up to 12-month follow-up. However, the majority of patients remained symptomatic and vulnerable to a range of risks at 12-month follow-up, indicating that longer-term monitoring is advisable in this population. Future research should focus on enhancing the efficacy of CBT in order to improve long-term outcomes.

The effect of self-focused attention and mood on appearance dissatisfaction after mirror-gazing: An experimental study.

BACKGROUND AND OBJECTIVES: Self-focused attention is hypothesized to be a maintenance factor in body dysmorphic disorder (BDD). The aim of this study was to use an experimental paradigm to test this hypothesis by studying the effect of self-focused attention during mirror-gazing on appearance dissatisfaction. METHODS: An experimental group design was used, in which 173 women were randomly allocated to one of three conditions before mirror-gazing for 2 min: (a) external focus of attention, (b) self-focus of attention, and (c) self-focus of attention with a negative mood induction. RESULTS: After mirror-gazing, participants across all groups rated themselves as being more dissatisfied with their appearance. In both the self-focus conditions, there was an increase in sadness from pre to post mirror gazing, and there was a significant difference in focus of attention for participants in the self-focused, mood-induced group from pre to post manipulation, suggesting mood induction had more of an effect than focus of attention. LIMITATIONS: (1) there was no condition involving an external focus with a negative mood induction, and (2) due to the level of information provided to patients on the nature of the task, we cannot rule out demand characteristics as an influencing factor on our results. CONCLUSIONS: Self-focused attention during mirror-gazing may act indirectly to increase appearance dissatisfaction via the effect of negative mood. Further studies are required to establish the relative contribution of self-focused attention and negative mood to increases in appearance dissatisfaction as a function of mirror-gazing.

Long-Term Outcome of Cognitive Behavior Therapy for Body Dysmorphic Disorder: A Naturalistic Case Series of 1 to 4 Years After a Controlled Trial.

There is some evidence for the efficacy of cognitive behavior therapy (CBT) for body dysmorphic disorder (BDD) after 1 to 6months but none in the long term. The aim of this study was to follow up the participants in a randomized controlled trial of CBT versus anxiety management to determine whether or not the treatment gains were maintained over time. Thirty of the original 39 participants who had CBT were followed up over 1 to 4years and assessed using a number of clinician and self-report measures, which included the primary outcome measure of the Yale-Brown Obsessive Compulsive Scale modified for BDD. Outcome scores generally maintained over time from end of treatment to long-term follow-up. There was a slight deterioration from n=20 (51.3%) to n=18 (46.2%) who met improvement criteria at long-term follow-up. Eleven (28.2%) were in full remission and 22 (56.4%) were in partial remission. The gains made were generally maintained at long-term follow-up. However, there were a significant number of participants who maintained chronic symptoms after treatment and may need a longer-term or more complex intervention and active medication management.

A Pilot Randomized Controlled Trial of Cognitive-Behavioral Therapy for Adolescents With Body Dysmorphic Disorder.

OBJECTIVE: Body dysmorphic disorder (BDD) typically starts in adolescence, but evidence-based treatments are yet to be developed and formally evaluated in this age group. We designed an age-appropriate cognitive-behavioral therapy (CBT) protocol for adolescents with BDD and evaluated its acceptability and efficacy in a pilot randomized controlled trial. METHOD: Thirty adolescents aged 12 to 18 years (mean = 16.0, SD = 1.7) with a primary diagnosis of BDD, together with their families, were randomly assigned to 14 sessions of CBT delivered over 4 months or a control condition of equivalent duration, consisting of written psycho-education materials and weekly telephone monitoring. Blinded evaluators assessed participants at baseline, midtreatment, posttreatment, and at 2-month follow-up. The primary outcome measure was the Yale-Brown Obsessive-Compulsive Scale Modified for BDD, Adolescent Version (mean baseline score = 37.13, SD = 4.98, range = 24-43). RESULTS: The CBT group showed a significantly greater improvement than the control group, both at posttreatment (time × group interaction coefficient [95% CI] = -11.26 [-17.22 to -5.31]; p = .000) and at 2-month follow-up (time × group interaction coefficient [95% CI] = -9.62 [-15.74 to -3.51]; p = .002). Six participants (40%) in the CBT group and 1 participant (6.7%) in the control condition were classified as responders at both time points (χ(2) = 4.658, p = .031). Improvements were also seen on secondary measures, including insight, depression, and quality of life at posttreatment. Both patients and their families deemed the treatment as highly acceptable. CONCLUSION: Developmentally tailored CBT is a promising intervention for young people with BDD, although there is significant room for improvement. Further clinical trials incorporating lessons learned in this pilot study and comparing CBT and pharmacological therapies, as well as their combination, are warranted. CLINICAL TRIAL REGISTRATION INFORMATION: Cognitive-Behaviour Therapy for Adolescents With Body Dysmorphic Disorder; http://www.isrctn.com/; ISRCTN67699666.

Appearance comparison in individuals with body dysmorphic disorder and controls.

Research investigating appearance comparison in body dysmorphic disorder (BDD) remains very limited, despite the fact that this is one of the most commonly observed behaviors in individuals with the disorder. The present study investigated the self-reported extent and nature of appearance comparison in 35 BDD participants relative to 45 controls using a newly devised and a standardized appearance comparison measure. The results showed that BDD participants reported significantly higher levels of appearance comparison than controls. Individuals with BDD also reported greater levels of comparing in terms of the specific feature(s) of their appearance they were most concerned about as compared to overall appearance, whilst controls showed the opposite pattern. Levels of comparing in BDD participants increased as targets increased in terms of attractiveness, and individuals with BDD rated themselves as being markedly less attractive than targets, and feeling markedly less satisfied with their appearance after comparing. Cognitive-behavioral treatment implications are discussed.

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 [ß = -7.19; SE (ß) = 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.

Holistic versus detailed visual processing in body dysmorphic disorder: testing the inversion, composite and global precedence effects.

Individuals with Body Dysmorphic Disorder (BDD) are preoccupied with perceived defects in their appearance that are not visible to others. An excessive focus and processing of details has been proposed as a possible mechanism underlying this distorted self-image in BDD. The nature and extent of visuoperceptual abnormalities in BDD however require further investigation; specifically, it remains unclear whether feature-based processing in BDD is a result of a failure of holistic perceptual processes. The present study evaluated whether BDD is associated with an impairment in global processing. Twenty-five individuals with a primary diagnosis of BDD (15 unmedicated, 10 medicated) and 25 matched healthy controls were administered three robust behavioural tasks that test holistic encoding, namely the face inversion, the composite and the navon tasks. Overall, individuals in the BDD and control groups performed similarly in all aspects of holistic processing tested. Our findings suggest that the excessive focus on specific aspects of appearance in BDD may not be explained by impairments in the global encoding of visual information. Implications of these results and suggestions for future research on visual processing in BDD are discussed.

Social-evaluative versus self-evaluative appearance concerns in Body Dysmorphic Disorder.

Body Dysmorphic Disorder (BDD) is characterised by significant preoccupation and distress relating to an imagined or slight defect in appearance. Individuals with BDD frequently report marked concerns relating to perceived negative evaluation of their appearance by others, but research specifically investigating such concerns remains limited. This study investigated the extent and nature of appearance-related social-evaluative and self-evaluative concerns in individuals with BDD and healthy controls. BDD participants, in comparison to controls, reported high levels of importance and anxiety associated with perceptions of others' views of their appearance, in addition to their own view. No differences were observed in the level of importance and anxiety associated with their self-view in comparison to others' views. These findings support existing evidence indicating that appearance-related social-evaluative concerns are a central feature of BDD. Cognitive-behavioural treatment implications are discussed.

The stopping criteria for mirror-gazing in body dysmorphic disorder.

OBJECTIVES: To investigate whether prolonged compulsive mirror-gazing in body dysmorphic disorder (BDD) is characterized by the prioritization of internally referenced (internal) goals for the mirror session, such as feeling right about one's make-up or shaven face, over externally referenced (external) goals, such as seeing that one's make-up is applied, or seeing that there is no more stubble on one's face. DESIGN: Cross-sectional case control. METHODS: Twenty-one participants with BDD and 18 community controls (CCs) recalled a recent mirror session in a semi-structured interview and then completed the Mirror-Gazing Goals and Terminating Factors Questionnaire (MGGTFQ), an instrument developed for the present study. RESULTS: Internal goals were rated as more important in the BDD group than the CC group, but there was no difference between groups in the importance of external goals. The BDD group identified internal goals significantly more frequently than the CC group among their three most important goals. The BDD group reported significantly lower achievement ratings for the three most important goals and were more likely to terminate the session for reasons unrelated to their goals (e.g., frustration). For all participants, the importance of internal goals was positively correlated with the length of the mirror session. CONCLUSIONS: The findings support current recommendations for targeting internal goals in interventions for problematic mirror use. Limitations and future directions are discussed, including the need to establish whether the use of internal goals is causally related to the length of the mirror session. PRACTITIONER POINTS: • BDD patients prioritize internal goals defined by feeling states when they look in the mirror (e.g., they aim above all to feel right about their make-up or shaven face), and then tend not to achieve their goals and end the mirror session for reasons unrelated to their goals (e.g., distress or time constraints). • Educating patients about these potentially problematic 'internal' goals, and encouraging them to aim for alternative goals (e.g., a fixed length of time, or an external goal defined by visual cues) might help patients to reduce the time they spend looking in the mirror. • The study is limited by the correlational design, the reliance on retrospective reporting, and the lack of a clinical control group.

Evidence for a genetic overlap between body dysmorphic concerns and obsessive-compulsive symptoms in an adult female community twin sample.

Body dysmorphic disorder (BDD) is thought to be etiologically related to obsessive-compulsive disorder (OCD) but the available evidence is incomplete. The current study examined the genetic and environmental sources of covariance between body dysmorphic and obsessive-compulsive symptoms in a community sample of adult twins. A total of 2,148 female twins (1,074 pairs) completed valid and reliable measures of body dysmorphic concerns and obsessive-compulsive symptoms. The data were analyzed using bivariate twin modeling methods and the statistical programme Mx. In the best-fitting model, the covariation between body dysmorphic and obsessive-compulsive traits was largely accounted for by genetic influences common to both phenotypes (64%; 95% CI: 0.50-0.80). This genetic overlap was even higher when specific obsessive-compulsive symptom dimensions were considered, with up to 82% of the phenotypic correlation between the obsessing and symmetry/ordering symptom dimensions and dysmorphic concerns being attributable to common genetic factors. Unique environmental factors, although influencing these traits individually, did not substantially contribute to their covariation. The results remained unchanged when excluding individuals reporting an objective medical condition/injury accounting for their concern in physical appearance. The association between body dysmorphic concerns and obsessive-compulsive symptoms is largely explained by shared genetic factors. Environmental risk factors were largely unique to each phenotype. These results support current recommendations to group BDD together with OCD in the same DSM-5 chapter, although comparison with other phenotypes such as somatoform disorders and social phobia is needed.

Mirror gazing in body dysmorphic disorder and healthy controls: effects of duration of gazing.

Cognitive-behavioural models of body dysmorphic disorder (BDD) suggest that mirrors can act as a trigger for individuals with BDD, resulting in a specific mode of cognitive processing, characterised by an increase in self-focussed attention and associated distress. The aim of the current study was to investigate these factors experimentally by exposing participants with BDD (n=25) and without BDD (n=25) to a mirror in a controlled setting. An additional aim was to ascertain the role of duration of mirror gazing in the maintenance of distress and self-consciousness by manipulating the length of gazing (short check vs. long gazing). Findings demonstrated that contrary to what was predicted, not only participants with BDD, but also those without BDD experienced an increase in distress and self-focused attention upon exposure to the mirror. In addition, people without BDD, unlike those with BDD, experienced more distress when looking in the mirror for a long period of time as opposed to a short period of time. This lends some support to the idea that, for people with BDD, gazing in a mirror, regardless of duration, might act as an immediate trigger for an abnormal mode of processing and associated distress, and that this association has developed from past excessive mirror gazing. Further theoretical implications of these findings, as well as subsidiary research questions relating to additional cognitive factors are discussed.

Obsessions and compulsions in Asperger syndrome and high-functioning autism.

BACKGROUND: Obsessive-compulsive behaviours are common and disabling in autistic-spectrum disorders (ASD) but little is known about how they compare with those experienced by people with obsessive-compulsive disorder (OCD). AIM: To make such a comparison. METHOD: A group of adults with high-functioning ASD (n=40) were administered the Yale-Brown Obsessive-Compulsive Scale and Symptom Checklist and their symptoms compared with a gender-matched group of adults with a primary diagnosis of OCD (n=45). OCD symptoms were carefully distinguished from stereotypic behaviours and interests usually displayed by those with ASD. RESULTS: The two groups had similar frequencies of obsessive-compulsive symptoms, with only somatic obsessions and repeating rituals being more common in the OCD group. The OCD group had higher obsessive-compulsive symptom severity ratings but up to 50% of the ASD group reported at least moderate levels of interference from their symptoms. CONCLUSIONS: Obsessions and compulsions are both common in adults with high-functioning ASD and are associated with significant levels of distress.