Empirically defining treatment response and remission in body dysmorphic disorder.

BACKGROUND: The number of clinical trials in body dysmorphic disorder (BDD) has steadily increased in recent years. As the number of studies grows, it is important to define the most empirically useful definitions for response and remission in order to enhance field-wide consistency and comparisons of treatment outcomes across studies. In this study, we aim to operationally define treatment response and remission in BDD. METHOD: We pooled data from three randomized controlled trials of cognitive-behavior therapy (CBT) for BDD (combined n = 153) conducted at four academic sites in Sweden, the USA, and England. Using signal detection methods, we examined the Yale-Brown Obsessive Compulsive Scale modified for BDD (BDD-YBOCS) score that most reliably identified patients who responded to CBT and those who achieved remission from BDD symptoms at the end of treatment. RESULTS: A BDD-YBOCS reduction ⩾30% was most predictive of treatment response as defined by the Clinical Global Impression (CGI) - Improvement scale (sensitivity 0.89, specificity 0.91, 91% correctly classified). At post-treatment, a BDD-YBOCS score ⩽16 was the best predictor of full or partial symptom remission (sensitivity 0.85, specificity 0.99, 97% correctly classified), defined by the CGI - Severity scale. CONCLUSION: Based on these results, we propose conceptual and operational definitions of response and full or partial remission in BDD. A consensus regarding these constructs will improve the interpretation and comparison of future clinical trials, as well as improve communication among researchers, clinicians, and patients. Further research is needed, especially regarding definitions of full remission, recovery, and relapse.

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.

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.

A critical review of cosmetic treatment outcomes in body dysmorphic disorder.

A high proportion of individuals with body dysmorphic disorder (BDD) undergo cosmetic treatments in an attempt to 'fix' perceived defect/s in their physical appearance. Despite the frequency with which such procedures are sought, few studies have prospectively examined the outcomes of cosmetic procedures in individuals with BDD. This article aims to critically review the literature and discuss the current debate that exists on outcomes of cosmetic treatment for individuals with BDD. An emerging literature suggests the majority of individuals with BDD have poor outcomes after cosmetic interventions; however, based on the current literature, it cannot be fully ruled out that certain individuals with mild BDD and localised appearance concerns may benefit from these interventions. Gaps in the current literature are highlighted, alongside recommendations for future research. Carefully conducted longitudinal studies with well-characterised patient populations are needed.

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.

'Eventually you just get used to it': an interpretative phenomenological analysis of 10-16 year-old girls' experiences of the transition into temporary accommodation after exposure to domestic violence perpetrated by men against their mothers.

Moving suddenly into temporary accommodation with their mothers is a reality for many children who live with domestic violence. The experience of this transition is under-researched despite being considered a unique event for children alongside that of being exposed to domestic violence involving their mothers. This piece of qualitative research aimed to address the following question: 'How do girls aged 10-16 years old experience the transition into temporary accommodation following exposure to domestic violence'? Five girls aged 10-16 years who had moved into either refuge or 'bed and breakfast' accommodation with their mothers were interviewed. Interviews were analysed using interpretative phenomenological analysis. Three master themes emerged: (1) 'Out of their hands: The transition into a whole new world with loss and change', (2) 'The relentlessness of feeling unsafe and uncertain', (3) 'Coping with the transition: At the mercy of their environment and the actions of others'. All themes show how a lack of agency was experienced by the girls throughout the transition. Findings suggest that the environment of temporary accommodation may inhibit the child's capacity to emotionally process the transition. The role of others was central to either facilitating or constraining coping for the girls throughout this transition.

Towards a richer understanding of school-age children's experiences of domestic violence: the voices of children and their mothers.

Millions of children are exposed to domestic violence. How children negotiate and make sense of living with domestic violence is still under-researched. This study sought to capture the dual-perspectives of school-aged children and their mothers, to develop a richer understanding of children's experiences of domestic violence, using a community-based sample. A qualitative research design was employed, with interpretative phenomenological analysis used to interpret the data. Five school-aged children and three of their mothers participated in the study. Two master themes are discussed from the analysis of the children's perspective: domestic violence through the eyes of children; and learning from children's experiences. Two master themes are discussed from the analysis of the mothers' perspective: reflecting on the child in the context of domestic violence; and learning from mothers: insights, support and services. The crucial importance of the mother-child relationship in shaping children's experience of domestic violence was illustrated in both the perspectives; a finding which may have important implications for the development of interventions. It was also evident that children as young as eight were able to powerfully articulate their experiences of domestic violence.

Developing a compassionate mind to enhance trauma-focused CBT with an adolescent female: a case study.

BACKGROUND: Shame and disgust are often associated with posttraumatic stress disorder (PTSD) following interpersonal traumas such as sexual assault. It has been suggested that individuals with high levels of shame might do less well in standard cognitive behavioural (CBT) interventions. AIMS: To see whether applying compassion-focused therapy and developing a compassionate mind can enhance trauma-focused CBT in an adolescent with high levels of shame and disgust the way it has been shown to within the adult population. METHOD: This single case study describes how trauma-focused CBT was enhanced by compassionate mind training. It details work using this approach with an adolescent female experiencing shame and disgust-based flashbacks. Treatment was provided for 20 sessions over 8 months. Symptoms of PTSD, depression and self-criticism, as well as the ability to self-soothe/reassure, were measured at assessment/start of treatment, mid- and end of treatment. RESULTS: Clinically significant reductions in PTSD, depressive, shame and self-attacking symptoms were found between assessment and completion of treatment. Clinically significant increases in self-reassurance were also reported. Following treatment, symptoms of PTSD and depression were sub-clinical. CONCLUSION: This case study suggests that developing a compassionate mind alongside trauma-focused CBT may be beneficial to adolescents experiencing shame and disgust with consideration for the young person's level of development and personal circumstances.