Relationship between social anxiety disorder and body dysmorphic disorder

Body image in social anxiety disorder, obsessive-compulsive disorder, and panic disorder

Body dysmorphic disorder falls under the category of obsessive-compulsive and related disorders, yet research has suggested it may also be highly associated with social anxiety disorder. The current study examined body image variables among 68 outpatients with primary obsessive-compulsive disorder (OCD; n=22), social anxiety disorder (SAD; n=25), and panic disorder (PD; n=21). Participants filled out self-report measures of body image disturbance, attitudes toward one's appearance, and anxiety. Body image disturbance and attitudes toward appearance did not significantly differ between the groups. However, SAD symptoms predicted body image disturbance, Appearance Evaluation and Body Areas Satisfaction, and OCD symptoms predicted Appearance Orientation. These findings suggest that SAD and OCD may be associated with different facets of body image. Implications for the treatment of anxiety disorders and for future research are discussed.

Psychological treatment of social anxiety disorder improves body dysmorphic concerns

Social anxiety disorder and body dysmorphic disorder are considered nosologically distinct disorders. In contrast, some cognitive models suggest that social anxiety disorder and body dysmorphic disorder share similar cognitive maintenance factors. The aim of this study was to examine the effects of psychological treatments for social anxiety disorder on body dysmorphic disorder concerns. In Study 1, we found that 12 weekly group sessions of cognitive-behavioral therapy led to significant decreases in body dysmorphic symptom severity. In Study 2, we found that an attention retraining intervention for social anxiety disorder was associated with a reduction in body dysmorphic concerns, compared to a placebo control condition. These findings support the notion that psychological treatments for individuals with primary social anxiety disorder improve co-occurring body dysmorphic disorder symptoms.

Associations Between Fear of Negative Evaluation and Eating Pathology During Intervention and 12-Month Follow-up

Fear of negative evaluation, a core feature of social anxiety disorder, has been prospectively related to eating pathology over and above other established risk factors, suggesting that it may be an important cognitive risk factor for eating disorders. The present study examined reciprocal longitudinal relations among fear of negative evaluation and eating disorder risk factors using a female undergraduate sample (N=82) enrolled in an eating disorder prevention program. Cross-lagged panel analysis revealed that fear of negative evaluation was a determinant of subsequent body dissatisfaction and eating disorder symptoms. Fear of negative evaluation also predicted subsequent thin-ideal internalization among participants with high BMI, but not among those with low BMI. Fear of negative evaluation did not predict future dietary restraint or negative affect but was itself predicted by prior levels of thin ideal internalization, body dissatisfaction, dietary restraint, and negative affect. Findings suggest that fear of negative evaluation may be a useful target for reducing body image concerns and maladaptive eating behavior.

Möglichkeiten zur klinischen Differenzierung von körperdysmorpher Störung und sozialer Angststörung

Theoretischer Hintergrund: Die körperdysmorphe Störung (KDS) und die soziale Angststörung (SA) teilen einige phänomenologische Merkmale (z. B. soziale Ängste, depressive Beschwerden). Bisher ist unklar, welche spezifischen Instrumente in der klinischen Praxis geeignet sind, um die Störungen zuverlässig voneinander abgrenzen zu können. Fragestellung: Zwischen beiden Störungen erwarten wir keine Unterschiede hinsichtlich des Ausmaßes depressiver Symptome, globaler psychischer Belastung und dem Selbstwert. Personen mit einer SA sollten hingegen ein höheres Ausmaß an sozialer Angst empfinden als KDS-Patienten, aber dafür ihr äußeres Erscheinungsbild als weniger relevant erachten. Fragebögen, die soziale Angst sowie Investition in und Relevanz des Erscheinungsbildes erfassen, sollten beide Störungen voneinander abgrenzen können. Methode: Von 43 Teilnehmern (n = 23 Personen mit KDS, n = 20 Personen mit SA) wurden das Beck Depressionsinventar (BDI), das Brief Symptom Inventory (BSI), die Social Phobia Scale (SPS) und Social Interaction Anxiety Scale (SIAS), die Rosenberg Self-Esteem Scale (RSE) und das Appearance Schemas Inventory-Revised (ASI-R) ausgefüllt. Ferner wurde die für die KDS modifizierte Yale-Brown Obsessive Compulsive Scale (BDD-YBOCS) durchgeführt. Ergebnisse: KDS und SA unterscheiden sich nicht bedeutsam hinsichtlich depressiver Symptome, globaler psychischer Belastung, ihrem Selbstwert oder in ihrer sozialen Angst in Leistungssituationen. In Interaktionssituationen zeigen die Personen mit SA bedeutsam mehr Furcht als KDS-Patienten. Personen mit KDS messen dem Erscheinungsbild eine extrem hohe Bedeutung zu, investieren mehr in ihr Aussehen und zeigen mehr aussehensbezogene Zwangssymptome. Eine Entscheidungsbaumanalyse zeigt, dass mit der BDD-YBOCS KDS-Patienten zu 96 %, mit dem ASI-R zu 86 % in der vorliegenden Stichprobe korrekt identifiziert werden können. Die SIAS eignet sich hingegen nicht zur Differenzierung. Schlussfolgerung: Es zeigen sich Unterschiede in dem Ausmaß sozialer Ängste und aussehensrelevanter Standards. Hohe soziale Interaktionsängste können auch ein Zeichen für eine KDS darstellen und sollten in der klinischen Praxis als Indikator für ein KDS-Screening genutzt werden.

Kognitive Therapie bei körperdysmorpher Störung

In den letzten Jahren ist die Erkenntnis gewachsen, dass die Körperdysmorphe Störung (KDS) viele Gemeinsamkeiten hinsichtlich klinischer Charakteristika und aufrechterhaltender Prozesse mit Zwangsstörungen (z. B. ritualisierte Kontrollhandlungen, wiederkehrende persistierende Gedanken) und sozialer Angststörung (z. B. exzessive Selbstaufmerksamkeit, mentale Vorstellungsbilder) aufweist. Neuere Behandlungsansätze bei KDS fokussieren insbesondere auf die Veränderung der gemeinsamen aufrechterhaltenden Prozesse. Diese Ansätze verbinden klassische kognitiv-behaviorale Techniken (Exposition mit Reaktionsverhinderung und kognitive Umstrukturierung) mit Interventionen aus der Kognitiven Therapie (Aufmerksamkeitstraining, Imagery Rescripting, Videofeedback, Verhaltensexperimente). Im vorliegenden Artikel werden die unterschiedlichen Behandlungsbausteine vorgestellt und die Vorgehensweise detailliert beschrieben. Die Interventionen aus der Kognitiven Therapie haben sich aus klinischer Erfahrung bei der Behandlung als hilfreich erwiesen, wurden bislang jedoch noch nicht für die KDS evaluiert.

Support system for decision making in the identification of risk for body dysmorphic disorder: a fuzzy model

PURPOSE

To develop a fuzzy linguistic model to quantify the level of distress of patients seeking cosmetic surgery. Body dysmorphic disorder (BDD) is a mental condition related to body image relatively common among cosmetic surgery patients; it is difficult to diagnose and is a significant cause of morbidity and mortality. Fuzzy cognitive maps are an efficient tool based on human knowledge and experience that can handle uncertainty in identifying or grading BDD symptoms and the degree of body image dissatisfaction. Individuals who seek cosmetic procedures suffer from some degree of dissatisfaction with appearance.

METHODS

A fuzzy model was developed to measure distress levels in cosmetic surgery patients based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), diagnostic criterion B for BDD. We studied 288 patients of both sexes seeking abdominoplasty, rhinoplasty, or rhytidoplasty in a university hospital.

RESULTS

Patient distress ranged from "none" to "severe" (range=7.5-31.6; cutoff point=18; area under the ROC curve=0.923). There was a significant agreement between the fuzzy model and DSM-IV criterion B (kappa=0.805; p<0.001).

CONCLUSION

The fuzzy model measured distress levels with good accuracy, indicating that it can be used as a screening tool in cosmetic surgery and psychiatric practice.

The relationship between anorexia nervosa and body dysmorphic disorder

Anorexia nervosa (AN) and body dysmorphic disorder (BDD) are severe body image disorders that highly impair individuals in their daily functioning. They are discrete but overlapping nosological entities. In this review, we examine similarities between AN and BDD with regard to clinical, personality and demographic aspects, such as comorbidity, phenomenology, and treatment outcome. The review suggests that the two disorders are highly comorbid, and show similar ages of onset, illness trajectories, and comparable clinical and personality characteristics. However, important differences emerge in their responsiveness to psychosocial and psychopharmacological treatment, which are discussed. Clinical implications of these findings are summarized and directions for future research are delineated, with a focus on how current treatment components from each disorder may inform new interventions for both disorders.

White matter microstructure in body dysmorphic disorder and its clinical correlates

Body dysmorphic disorder (BDD) is characterized by an often-delusional preoccupation with misperceived defects of appearance, causing significant distress and disability. Although previous studies have found functional abnormalities in visual processing, frontostriatal, and limbic systems, no study to date has investigated the microstructure of white matter connecting these systems in BDD. Participants comprised 14 medication-free individuals with BDD and 16 healthy controls who were scanned using diffusion-weighted magnetic resonance imaging (MRI). We utilized probabilistic tractography to reconstruct tracts of interest, and tract-based spatial statistics to investigate whole brain white matter. To estimate white matter microstructure, we used fractional anisotropy (FA), mean diffusivity (MD), and linear and planar anisotropy (c(l) and c(p)). We correlated diffusion measures with clinical measures of symptom severity and poor insight/delusionality. Poor insight negatively correlated with FA and c(l) and positively correlated with MD in the inferior longitudinal fasciculus (ILF) and the forceps major (FM). FA and c(l) were lower in the ILF and the inferior fronto-occipital fasciculus and higher in the FM in the BDD group, but differences were nonsignificant. This is the first diffusion-weighted MR investigation of white matter in BDD. Results suggest a relationship between impairments in insight, a clinically important phenotype, and fiber disorganization in tracts connecting visual with emotion/memory processing systems.

A comparison study of body dysmorphic disorder versus social phobia

Body dysmorphic disorder (BDD) shares many characteristics with social phobia (SP), including high levels of social anxiety and avoidance, but to our knowledge no studies have directly compared these disorders' demographic and clinical features. Demographic and clinical features were compared in individuals with BDD (n=172), SP (n=644), and comorbid BDD/SP (n=125). SP participants had a significantly earlier age of onset and lower educational attainment than BDD participants. BDD participants were significantly less likely to ever be married than SP participants, had a greater likelihood of ever being psychiatrically hospitalized, and had significantly lower mean GAF scores than SP participants. The two groups had different comorbidity patterns, which included a greater likelihood for BDD participants to have comorbid obsessive-compulsive disorder (OCD) or an eating disorder, vs. a greater likelihood for SP participants to have a comorbid non-OCD anxiety disorder. The comorbid BDD/SP group had significantly greater morbidity across several domains than the SP only group, but not the BDD only group. In summary, although BDD and SP were similar across many demographic and clinical features, they had important differences. Future studies are needed to confirm these findings and address similarities and differences between these disorders across a broader range of variables.

Physical appearance anxiety impedes the therapeutic effects of video feedback in high socially anxious individuals

BACKGROUND

Video feedback (VF) interventions effectively reduce social anxiety symptoms and negative self-perception, particularly when they are preceded by cognitive preparation (CP) and followed by cognitive review.

AIMS

In the current study, we re-examined data from a study on the efficacy of a novel VF intervention for individuals high in social anxiety to test the hypothesis that physical appearance anxiety would moderate the effects of VF.

METHOD

Data were analyzed from 68 socially anxious participants who performed an initial public speech, and were randomly assigned to an Elaborated VF condition (VF plus cognitive preparation and cognitive review), a Standard VF condition (VF plus cognitive preparation) or a No VF condition (exposure alone), and then performed a second speech.

RESULTS

As hypothesized, when appearance concerns were low, both participants who received Elaborated and Standard VF were significantly less anxious during speech 2 than those in the No VF condition. However, when levels of appearance concern were high, neither Elaborated nor Standard VF reduced anxiety levels during speech 2 beyond the No VF condition.

CONCLUSIONS

Results from our analog sample suggest the importance of tailoring treatment protocols to accommodate the idiosyncratic concerns of socially anxious patients.

Social phobia in obsessive-compulsive disorder: prevalence and correlates

BACKGROUND

Social Phobia (SP) is an anxiety disorder that frequently co-occurs with obsessive-compulsive disorder (OCD); however, studies that evaluate clinical factors associated with this specific comorbidity are rare. The aim was to estimate the prevalence of SP in a large multicenter sample of OCD patients and compare the characteristics of individuals with and without SP.

METHOD

A cross-sectional study with 1001 patients of the Brazilian Research Consortium on Obsessive-Compulsive Spectrum Disorders using several assessment instruments, including the Dimensional Yale-Brown Obsessive-Compulsive Scale and the Structured Clinical Interview for DSM-IV Axis I Disorders. Univariate analyses were followed by logistic regression.

RESULTS

Lifetime prevalence of SP was 34.6% (N=346). The following variables remained associated with SP comorbidity after logistic regression: male sex, lower socioeconomic status, body dysmorphic disorder, specific phobia, dysthymia, generalized anxiety disorder, agoraphobia, Tourette syndrome and binge eating disorder.

LIMITATIONS

The cross-sectional design does not permit the inference of causal relationships; some retrospective information may have been subject to recall bias; all patients were being treated in tertiary services, therefore generalization of the results to other samples of OCD sufferers should be cautious. Despite the large sample size, some hypotheses may not have been confirmed due to the small number of cases with these characteristics (type 2 error).

CONCLUSION

SP is frequent among OCD patients and co-occurs with other disorders that have common phenomenological features. These findings have important implications for clinical practice, indicating the need for broader treatment approaches for individuals with this profile.

Body dysmorphic disorder in patients with obsessive-compulsive disorder: prevalence and clinical correlates

BACKGROUND

The prevalence, sociodemographic aspects, and clinical features of body dysmorphic disorder (BDD) in patients with obsessive-compulsive disorder (OCD) have been previously addressed in primarily relatively small samples.

METHODS

We performed a cross-sectional demographic and clinical assessment of 901 OCD patients participating in the Brazilian Research Consortium on Obsessive-Compulsive Spectrum Disorders. We used the Structured Clinical Interview for DSM-IV Axis I Disorders; Yale-Brown Obsessive-Compulsive Scale; Dimensional Yale-Brown Obsessive-Compulsive Scale (DY-BOCS); Brown Assessment of Beliefs Scale; Clinical Global Impression Scale; and Beck Depression and Anxiety Inventories.

RESULTS

The lifetime prevalence of BDD was 12.1%. The individuals with comorbid BDD (OCD-BDD; n = 109) were younger than were those without it. In addition, the proportions of single and unemployed patients were greater in the OCD-BDD group. This group of patients also showed higher rates of suicidal behaviors; mood, anxiety, and eating disorders; hypochondriasis; skin picking; Tourette syndrome; and symptoms of the sexual/religious, aggressive, and miscellaneous dimensions. Furthermore, OCD-BDD patients had an earlier onset of OC symptoms; greater severity of OCD, depression, and anxiety symptoms; and poorer insight. After logistic regression, the following features were associated with OCD-BDD: current age; age at OCD onset; severity of the miscellaneous DY-BOCS dimension; severity of depressive symptoms; and comorbid social phobia, dysthymia, anorexia nervosa, bulimia nervosa, and skin picking.

CONCLUSIONS

Because OCD patients might not inform clinicians about concerns regarding their appearance, it is essential to investigate symptoms of BDD, especially in young patients with early onset and comorbid social anxiety, chronic depression, skin picking, or eating disorders.

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.

Rejection sensitivity mediates the relationship between social anxiety and body dysmorphic concerns

The goal of this study was to examine the role of rejection sensitivity in the relationship between social anxiety and body dysmorphic concerns. To test our hypothesis that rejection sensitivity mediates the link between social anxiety and body dysmorphic concerns, we administered self-report questionnaires to 209 student volunteers. Consistent with our prediction, rejection sensitivity partially mediated the relationship between social anxiety symptoms and body dysmorphic concerns. The implications of the overlap between these constructs are discussed.