Body dysmorphic disorder and other clinically significant body image concerns in adolescent psychiatric inpatients: prevalence and clinical characteristics

Practitioner Review: Assessment and treatment of body dysmorphic disorder in young people

Body dysmorphic disorder (BDD) is a relatively common and highly impairing mental disorder that is strikingly underdiagnosed and undertreated in Child and Adolescent Mental Health Services (CAMHS). The only clinical guidelines for the management of BDD in youth were published nearly 20 years ago, when empirical knowledge was sparse. Fortunately, there has been a surge in research into BDD over the last 10 years, shedding important insights into the phenomenology, epidemiology, assessment and treatment of the disorder in young people. This review aimed to provide an overview of recent research developments of relevance to clinicians and healthcare policymakers. We summarise key findings regarding the epidemiology of BDD in youth, which indicate that the disorder usually develops during teenage years and affects approximately 2% of adolescents at any one point in time. We provide an overview of aetiological research, highlighting that BDD arises from an interplay between genetic and environmental influences. We then focus on screening and assessment strategies, arguing that these are crucial to promote detection and diagnosis of this under-recognised condition. Additionally, we summarise the recommended treatment approaches for BDD in youth, namely cognitive behaviour therapy with or without selective serotonin reuptake inhibitors. The review concludes by highlighting key knowledge gaps and priorities for future research including, but not limited to, better understanding aetiological factors, long-term consequences and treatment.

The Association Between Childhood Maltreatment and Body (dis)satisfaction in Adolescents and Young Adults from the General Population

Adolescents with a history of childhood maltreatment are vulnerable to body dissatisfaction and associated psychopathology such as eating disorders. The aim of this study was to expand the understanding of the association between childhood maltreatment and body dissatisfaction in adolescents and young adults. In an epidemiological cohort study, N = 1,001 participants aged 14-21 years from Dresden, Germany, completed self-report measures on childhood maltreatment, body image, and self-esteem. Lifetime mental disorders were assessed in standardized clinical interviews. Data analyses included multiple regression and mediation analyses. More than one-third of the participants reported experiences of childhood maltreatment (37.4%), in which emotional neglect and abuse were the most frequent subtypes. Individuals with a history of childhood maltreatment showed significantly less satisfaction with their physical appearance than participants without such adverse experiences. In a single mediator model, self-esteem emerged as potential mediator in the association between child maltreatment and body (dis)satisfaction. Experiences of childhood maltreatment may be considered as risk factor for the development of body dissatisfaction in adolescents, and the role of potential mediator variables such as self-esteem warrants further prospective research.

The DIAMOND-KID: Psychometric Properties of a Structured Diagnostic Interview for DSM-5 Anxiety, Mood, and Obsessive-Compulsive and Related Disorders in Children and Adolescents

The objective of the present study was to examine the reliability and validity of a new semi-structured interview for pediatric psychiatric disorders, which is needed as existing interviews do not cover the full range of anxiety, mood, and obsessive-compulsive disorder (OCD)-related disorders. Three hundred eleven child patients (aged 10-17) were administered the Diagnostic Interview for Anxiety, Mood, and OCD and Related Neuropsychiatric Disorders-Child and Adolescent Version (DIAMOND-KID). Of these, 65 provided interrater reliability data and 59 provided test-retest reliability data. Participants also completed self-report measures that assessed symptoms of anxiety, mood, and OCD and related disorders. Although parents/guardians could participate in the interview at the clinician's discretion, most of the initial interviews and all of the reliability interviews were based on the child's self-report. Test-retest reliability ranged from very good to excellent. Interrater reliability was more variable, with estimates for generalized anxiety disorder and major depressive disorder in the questionable range; the other interrater reliability estimates ranged from good to very good. Convergent validity was established by significant between-group comparisons on applicable self-report measures for all diagnoses. The results of the present study indicate that the DIAMOND-KID is a promising semi-structured diagnostic interview for 5th edition of the Diagnostic and Statistical Manual of Mental Disorders in pediatric populations.

Psychometric Evaluation of the Yale-Brown Obsessive-Compulsive Scale Modified for Body Dysmorphic Disorder for Adolescents (BDD-YBOCS-A)

The Yale-Brown Obsessive-Compulsive Scale Modified for Body Dysmorphic Disorder for Adolescents (BDD-YBOCS-A) is a clinician-rated measure of BDD symptom severity in youth. Despite widespread use in both research and clinical practice, its psychometric properties have not been formally evaluated. The current study examined the factor structure, reliability, validity, and sensitivity to change of the BDD-YBOCS-A in 251 youths with BDD attending two specialist clinics. A principal component analysis identified two factors, explaining 56% of the variance. The scale showed good internal consistency (Cronbach's alpha = 0.87) and adequate convergent and divergent validity. In a subgroup of participants receiving BDD treatment (n = 175), BDD-YBOCS-A scores significantly decreased over time, demonstrating sensitivity to change. BDD-YBOCS-A change scores over treatment were highly correlated with severity changes measured by the Clinical Global Impression - Severity scale (r = .84). The study provides empirical support for the use of the BDD-YBOCS-A in children and adolescents with BDD.

Body Dysmorphic Disorder

This article summarizes current knowledge of body dysmorphic disorder across the life span. An overview of the epidemiology and phenomenology of this condition is provided, as well as clinical perspectives on assessment and treatment. Barriers to accessing treatment are considered, along with recent developments to improve access. Future directions in research and clinical care for this population are summarized.

“If only he were blind”: Shame, trauma, and dissociation among women with body dysmorphic disorder in physically intimate relationships

Background

Body Dysmorphic Disorder (BDD) involves a debilitating preoccupation with one’s appearance and associated difficulties in social and interpersonal relationships, according to the Diagnostic and Statistical Manual for Mental Disorders (DSM-5). Quantitative research has investigated the severity of relationship difficulties in BDD, while qualitative research has primarily focused on intrapersonal phenomena, although interpersonal difficulties, including with physical intimacy, have frequently emerged from these studies.

Aims

This study explores how women with BDD make sense of their lived experiences of physical intimacy in the context of current partner relationships.

Method

Six adult women participated in individual semi-structured interviews. The data was analysed using Interpretative Phenomenological Analysis.

Results

The analysis generated three superordinate themes: 1) The shame in being seen, 2) Disgust and detachment during intimacy, and 3) A flawed self, unworthy of relationships.

Conclusions

This study demonstrates how appearance-related concerns filter into the cognitive, behavioural, and emotional intersubjective spaces of physically intimate partnerships. Shame or trauma may be triggered and may be managed through disengagement or dissociation.

Clinical implications

These findings support calls for a full psychological assessment of the contextual and interpersonal components of BDD, and further suggest that psychological interventions for shame, trauma, and dissociation, such as compassion-focused therapy, imagery rescripting, or body-focused therapies, may be helpful additions to cognitive-behavioural or exposure and response prevention interventions for practitioners working with BDD.

The association between body dysmorphic symptoms and suicidality among adolescents and young adults: a genetically informative study

BACKGROUND

Previous research indicates that body dysmorphic disorder (BDD) is associated with risk of suicidality. However, studies have relied on small and/or specialist samples and largely focussed on adults, despite these difficulties commonly emerging in youth. Furthermore, the aetiology of the relationship remains unknown.

METHODS

Two independent twin samples were identified through the Child and Adolescent Twin Study in Sweden, at ages 18 (N = 6027) and 24 (N = 3454). Participants completed a self-report measure of BDD symptom severity. Young people and parents completed items assessing suicidal ideation/behaviours. Logistic regression models tested the association of suicidality outcomes with: (a) probable BDD, classified using an empirically derived cut-off; and (b) continuous scores of BDD symptoms. Bivariate genetic models examined the aetiology of the association between BDD symptoms and suicidality at both ages.

RESULTS

Suicidal ideation and behaviours were common among those with probable BDD at both ages. BDD symptoms, measured continuously, were linked with all aspects of suicidality, and associations generally remained significant after adjusting for depressive and anxiety symptoms. Genetic factors accounted for most of the covariance between BDD symptoms and suicidality (72.9 and 77.7% at ages 18 and 24, respectively), but with significant non-shared environmental influences (27.1 and 22.3% at ages 18 and 24, respectively).

CONCLUSIONS

BDD symptoms are associated with a substantial risk of suicidal ideation and behaviours in late adolescence and early adulthood. This relationship is largely explained by common genetic liability, but non-shared environmental effects are also significant and could provide opportunities for prevention among those at high-risk.

Video Conferencing Dysmorphia: Assessment of Pandemic-Related Body Dysmorphia and Implications for the Post-lockdown Era

Background: The coronavirus 2019 (COVID-19) pandemic has led to global effects on human interaction and mental health. The most drastic changes are seen in ways people continue to stay connected with each other. Video-conferencing applications like Zoom gained popularity and have become the primary means of communication for social or work events and meetings. These applications have also in many places replaced face-to-face healthcare visits and have penetrated school-based learning. The long-term implications of this digital technology on self-esteem and body image require further study.

Main Body: Video-conferencing applications have led to people being more conscious of their appearance and this has resulted in increased cases of body dysmorphic disorder (BDD). There is increased focus on body appearance and cosmetic procedures to fix minor defects. Although the treatment for BDD is like depression, it requires the personalization of therapy specific to the needs of the patient.

Conclusion: In this review, we aim to highlight the impact of the pandemic on body image and the long-term implications of virtual conferencing. The review also highlights available pharmacological and non-pharmacological treatment approaches in the management of body dysmorphic disorder related to virtual video conferencing.

Clinical characteristics of 172 children and adolescents with body dysmorphic disorder

Body dysmorphic disorder (BDD) often starts in childhood, with most cases developing symptoms before age 18. Yet, BDD research has primarily focused on adults. We report the clinical characteristics of the world's largest cohort of carefully diagnosed youths with BDD and focus on previously unexplored sex and age differences. We systematically collected clinical data from 172 young people with BDD consecutively referred to 2 specialist pediatric obsessive-compulsive and related disorders outpatient clinics in Stockholm, Sweden and in London, England. A series of clinician-, self-, and parent-reported measures were administered. The cohort consisted of 136 girls, 32 boys, and 4 transgender individuals (age range 10-19 years). The mean severity of BDD symptoms was in the moderate to severe range, with more than one third presenting with severe symptoms and more than half showing poor or absent insight/delusional beliefs. We observed high rates of current psychiatric comorbidity (71.5%), past or current self-harm (52.1%), suicide attempts (11.0%), current desire for cosmetic procedures (53.7%), and complete school dropout (32.4%). Compared to boys, girls had significantly more severe self-reported BDD symptoms, depression, suicidal thoughts, and self-harm. Compared to the younger participants (14 or younger), older participants had significantly more severe compulsions and were more likely to report a desire for conducting cosmetic procedures. Adolescent BDD can be a severe and disabling disorder associated with significant risks and substantial functional impairment. The clinical presentation of the disorder is largely similar across sexes and age groups, indicating the importance of early detection and treatment. More research is needed specifically focusing on boys and pre-pubertal individuals with BDD.

Body Dysmorphic Disorder: Clinical Overview and Relationship to Obsessive-Compulsive Disorder

Body dysmorphic disorder (BDD), characterized by a distressing or impairing preoccupation with nonexistent or slight defects in appearance, is associated with markedly poor quality of life and high rates of suicidality. Onset of BDD is usually in childhood or adolescence and, unless appropriately treated, tends to be chronic. The first-line pharmacologic approach for both delusional and non-delusional BDD is serotonin reuptake inhibitors (SRIs), often at high doses. SRI augmentation and switching strategies can be effective. The first-line psychotherapy is cognitive-behavioral therapy (CBT) tailored to BDD's unique clinical features. Cosmetic treatment (such as surgery or dermatologic treatment), although received by a majority of patients with BDD, is not recommended. BDD has many similarities to obsessive-compulsive disorder (OCD) and appears closely related to OCD but also has some important differences. This article, which updates a 2015 article on BDD that we published in this journal, provides a clinically focused overview of BDD and its relationship to OCD.

Body dysmorphic disorder in children and young people

The incidence of body dysmorphic disorder (BDD) in young people is increasing. Causes of BDD are related to the prevalence of social media and adolescent development, especially the role that brain neuroplasticity has on influencing perception. There are long-term impacts of BDD, including depression and suicide. Prevention and promotion of positive body image are part of the nurse's role; treatment can prevent unnecessary aesthetic surgical interventions.

The prevalence and determinants of body dysmorphic disorder among young social media users: A cross-sectional study

Social media that is heavily used in Saudi Arabia has been linked to a negative impact on body image satisfaction. The objective of the current study was to examine the burden, determinants, and impacts of Body Dysmorphic Disorder (BDD) among a community sample of social media users in Saudi Arabia. The Internet-based cross-sectional study was conducted among social media users during January and February 2020. BDD was assessed using a validated BDD Questionnaire. A total of 1010 participants were included in the current analysis. A total of 42 (4.2%) met the criteria of BDD, with higher prevalence in younger participants. The defects of high concerns were skin disfigurements (64.2%) and hair issues (42.3%). BDD was significantly associated with spending a longer time on Snapchat and Instagram and less interest in religious topics. BDD group was more likely to compare their appearance with famous people in social media. BDD group reported more harassment and more history of psychiatric problems. There is a need to educate the public about the risk of BDD and to promote safe social networking.

Prevalence of Body Dysmorphic Disorder and Predictors of Body Image Disturbance in Adolescence

Background:

Body dysmorphic disorder encompasses a range of cognitive and behavioural states stemming from distressing, negative evaluations of one’s appearance. Despite the seriousness of this condition, little is known about who is likely to receive a diagnosis and more importantly what the putative risk factors are. This is particularly so among adolescent samples, where the extant literature is considerably smaller.

Objective:

This study had two broad aims: to estimate the prevalence of body dysmorphic disorder within a young-adult population, and to examine the predictors of body image disturbance.

Methods:

Three-hundred and four adolescents (242 females; Mage = 17.68) completed the Body Image Disturbance Questionnaire and Body Dysmorphic Disorder Questionnaire, along with measures of clinical psychopathology, self-esteem, experiences of parenting, and bullying.

Results:

Body dysmorphic disorder was present in 3.9% of the sample, which is in line with previous estimates among adolescents. More interestingly, results indicated that instances of high stress, low self-esteem, and reported experiences of bullying were able to predict 48% of body image dissatisfaction.

Conclusions:

Psychological interventions should be directed towards adolescents with body image concerns, especially if they also report bullying, elevated stress, or diminished selfesteem. However, additional research is still warranted to gain an increasingly accurate understanding of the prevalence of body dysmorphic disorder and who is susceptible to developing this disorder and how we can best serve these individuals in the community.

A Brief Assessment of Body Image Perception: Norm Values and Factorial Structure of the Short Version of the FKB-20

The Body Image Questionnaire-20 (FKB-20) is one of the most applied self-report measures in the context of body image assessment in German-speaking regions. A version of the FKB-20 capturing an ideal concept of body image is also available. A special property of the scale is its high sensitivity for individuals suffering from anorexia nervosa. The present research provided a short version of this scale (for both variants) and examined its validity in a representative sample (N = 2,347) of the German population. We utilized factor analysis methods to identify the optimal short scale of the measure, finding excellent model fit and reliability for a two-factor model (FKB-6) for both real and ideal body image. Both versions of the FKB-6 can be considered invariant across sex and age groups. Good reliability indices were shown for both versions of the FKB-6. The reliability indices were similar to those mentioned in previous studies. Our study also revealed, that large discrepancies between the real and an ideal body image are correlated with somatic and body dysmorphic symptoms. Finally, we provided norm values for comparisons of individual scores with the general population. The FKB-6 is a valid and a reliable measure that economizes assessments by clinicians and researchers.

The psychometric properties of the Italian adaptation of the Health Orientation Scale (HOS)

Background

A novel approach suggested that cognitive and dispositional features may explain in depth the health behaviors adoption and the adherence to prevention programs. The Health Orientation Scale (HOS) has been extensively used to map the adoption of health and unhealthy behaviors according to cognitive and dispositional features. Coherently, the main aim of the current research was to assess the factor structure of the Italian version of the HOS using exploratory and confirmatory factor analysis and testing the construct validity of the scale by assessing differences in health orientations between tobacco cigarette smokers and nonsmokers.

Method

The research protocol was organized in two studies. Study 1 evaluated the dimensionality of the HOS in a sample of Northern Italian healthy people. Three hundred and twenty-one participants were enrolled; they were 229 women (71.3%) and 92 men (28.7%). In Study 2, the factor structure and construct validity of the HOS Italian version was assessed trough confirmatory factor analysis using a tobacco cigarette smokers and nonsmokers population. Two hundred and nineteen participants were enrolled; they were 164 women (75.2%) and 55 men (24.8%).

Results

In Study 1, a seven factors solution was obtained explaining 60% of cumulative variance instead of 10 factors solution of the original version of the HOS. In Study 2, the factor structure of the Italian version of the HOS was confirmed and applied to the smokers and nonsmokers; nonsmokers reported higher values than smokers in Factor 1 (MHPP) [t (208) = − 2.739 p < .007] (CI 95–4.96% to −.809), Factor 2 (HES) [t (209) = − 3.387 p < .001] (CI 95–3.93% to -. 1.03), Factor 3 (HIC) [t(213) = − 2.468 p < .014] (CI 95–2.56% to −.28) and Factor 7 (HEX) [t(217) = − 3.451 p < .001] (CI 95%- 1.45 to .39).

Conclusions

Results of the Italian adaptation of HOS lead to a partial redistribution of items and confirmed 7 subscales to distinguish psycho-cognitive dispositional dimensions involved in health orientation styles.

Treatment utilization and treatment barriers in individuals with body dysmorphic disorder

BACKGROUND

Although effective treatments are available, most individuals with body dysmorphic disorder (BDD) do not receive an appropriate diagnosis or treatment. We aimed to examine treatment utilization and barriers to treatment, and to identify associated socio-demographic and clinical characteristics.

METHODS

German individuals completed an online self-report survey of appearance concerns. A sample of N = 429 individuals met criteria for BDD. We examined the frequency of treatment utilization and barriers, analyzed comparisons between treated and untreated individuals and assessed the relationships of socio-demographic and clinical features with mental health treatment utilization and treatment barriers, respectively.

RESULTS

Only 15.2% of the individuals with BDD had been diagnosed with BDD, and lifetime rates of mental health treatment were low (39.9%). Individuals endorsed multiple barriers to mental health treatment, especially shame, low perceived need and a preference for cosmetic and medical treatments. Associated features were identified, including age, a BDD diagnosis, body dysmorphic symptom severity, a likely major depressive disorder, prior cosmetic surgery, and insight.

CONCLUSIONS

The results of this largest study to date highlight that BDD is still underrecognized and undertreated even in a country with extensive mental health care and few financial barriers. We discuss modifiable factors and strategies to foster awareness of BDD in sufferers and professionals to improve treatment dissemination and to reduce treatment barriers.

The Relative Associations of Body Image Dissatisfaction among Psychiatric Out-Patients in Singapore

Background: Adults with body image dissatisfaction (BID) are more likely to be depressed, anxious, and suicidal when compared to those without intense dissatisfaction over their appearance. The current study aimed to estimate the prevalence and factors associated with BID among out-patients with mental illness in Singapore. Methods: Data was collected from 310 psychiatric out-patients using a self-administered questionnaire. Measurements used were socio-demographic characteristics, Body Mass Index scores, Body Shape Questionnaire, Binge Eating Scale, Eating Attitudes Test, Beck’s Depression Inventory, Beck’s Anxiety Inventory and Alcohol Use Disorders Identification Test. Results: A prevalence of 30.9% of BID was established among psychiatric out-patients in Singapore. Being female, having higher BMI scores, binge eating behavior, eating disorders, and those diagnosed with depression were positively associated with BID. Conclusion: BID is prevalent among those with psychiatric illnesses which could lead to a higher degree of psychological distress and the emergence of eating disorders.

The Multidimensional Youth Body Dysmorphic Inventory: Development and Preliminary Validation

A new measure specifically designed for adolescents to assess body dysmorphic disorder (BDD) symptoms is needed to identify youth who could benefit from intervention to reduce their BDD-related symptomology. To address this gap, the Multidimensional Youth Body Dysmorphic Inventory (MY BODI) was developed and the psychometric properties were evaluated. Following development and expert assessment, Australian secondary school students (N = 582; 55% female; M_age = 13.62, SD = 1.59, aged 11 to 18 years, grades 7 to 12) completed a survey with the new items and validation measures. Results from the factor analysis supported a 3-factor, 21-items measure, which aligned with the DSM-5 diagnostic criteria of Impairment/avoidance, Preoccupation/repetitive behaviours, and Insight/distress. Supporting the convergent validity of the measure, the MY BODI total score and sub-scale scores correlated with measures of BDD symptoms, including the Appearance Anxiety Inventory (AAI) and Body Dysmorphic Disorder Questionnaire-Adolescent Version (BDDQ-A). This study provides preliminary validation of the MY BODI, a self-report measure of BDD symptoms and symptom severity, using a response set aimed to facilitate more reliable reporting, which may identify risk for BDD, and symptoms of BDD.

Active and Passive Social Media Use and Symptoms of Anxiety and Depressed Mood Among Icelandic Adolescents

Adolescent use of social media platforms such as Facebook, Instagram, and Snapchat has increased dramatically over the last decade and now pervades their everyday social lives. Active and passive social media use may impact emotional health differently, but little is known about whether and to what extent either type of social media use influences emotional distress among young people. We analyzed population survey data collected from Icelandic adolescents (N = 10,563) to document the prevalence of social media use and investigate the relationship of both active and passive social media use with self-reported symptoms of anxiety and depressed mood. A hierarchical linear regression model revealed that passive social media use was related to greater symptoms of anxiety and depressed mood among adolescents and active social media use was related to decreased symptoms of anxiety and depressed mood, even after controlling for time spent on social media. When adding known risk and protective factors, self-esteem, offline peer support, poor body image, and social comparison to the model, active use was not related to emotional distress; however, passive use was still related to adolescent symptoms of anxiety and depressed mood. The effect of social media on emotional distress differed by gender as time spent on social media had a stronger relationship with emotional distress among girls. In addition, passive use was more strongly related to symptoms of depressed mood among girls. Future research should include risk and protective factors as mediators of different types of social media use and adolescent emotional distress.

Prevalence and clinical characteristics of body dysmorphic disorder in adolescent inpatient psychiatric patients-a pilot study

Background: Body dysmorphic disorder (BDD) is preoccupation with perceived body defects leading to distress and impairment in social functioning. Most of adolescent BDD literature has been done on patients within the outpatient setting with prior versions of DSM with dearth of information about BDD and comorbid psychiatric conditions among adolescents within the inpatient setting. Aims: This pilot study evaluated the prevalence rate, clinical characteristics in adolescent BDD compared to non-BDD adolescents in a psychiatric in patient setting in addition to their comorbid issues like anxiety, OCD, ADHD and substance abuse. Methods: Forty-five consecutively admitted adolescent patients participated with 17 meeting the DSM 5 criteria for BDD while 28 did not. Patients were asked four questions designed around the DSM-5 criteria for BDD after which they were asked to complete questionnaires like BDDQ child and adolescent version, BDDM, Multiaxial Anxiety Scale for Children, Children's Depression Inventory, Y-BOCS and Vanderbilt ADHD rating scales. Results: Seventeen participants had BDD. Mean age of BDD patients was 13.1 while non-BDD was 12.4. Male patients with BDD were seven (41%) while female BDD patients were 10 (58.8%). Anxiety, depression, OCD and substance use disorders were common comorbid diagnoses. Majority of patients in the BDD group classified their BDD as a severe problem with more BDD, patient's considering suicide because of their BDD. Discussion: BDD is present in adolescents admitted in inpatient psychiatric hospital with more female patients endorsing BDD versus their male counterparts. Patients with BDD are more likely to endorse more comorbid psychiatric issues such as anxiety, OCD, ADHD and substance abuse.

Body image dissatisfaction in patients with inflammatory bowel disease: a systematic review

BACKGROUND AND AIMS

Little is known about the relationship between inflammatory bowel disease (IBD) and body image. The aim of this systematic review was to summarise the evidence on body image dissatisfaction in patients with IBD across four areas: (1) body image tools, (2) prevalence, (3) factors associated with body image dissatisfaction in IBD and (4) association between IBD and quality of life.

METHODS

Two reviewers screened, selected, quality assessed and extracted data from studies in duplicate. EMBASE, MEDLINE, PsycINFO and Cochrane CENTRAL were searched to April 2018. Study design-specific critical appraisal tools were used to assess risk of bias. Narrative analysis was undertaken due to heterogeneity.

RESULTS

Fifty-seven studies using a body image tool were included; 31 for prevalence and 16 and 8 for associated factors and association with quality of life, respectively. Studies reported mainly mean or median scores. Evidence suggested female gender, age, fatigue, disease activity and steroid use were associated with increased body image dissatisfaction, which was also associated with decreased quality of life.

CONCLUSION

This is the first systematic review on body image in patients with IBD. The evidence suggests that body image dissatisfaction can negatively impact patients, and certain factors are associated with increased body image dissatisfaction. Greater body image dissatisfaction was also associated with poorer quality of life. However, the methodological and reporting quality of studies was in some cases poor with considerable heterogeneity. Future IBD research should incorporate measurement of body image dissatisfaction using validated tools.

Understanding and treating body dysmorphic disorder

Body dysmorphic disorder (BDD), also known as dysmorphophobia, is a condition that consists of a distressing or impairing preoccupation with imagined or slight defects in appearance, associated repetitive behaviors and where insight regarding the appearance beliefs is often poor. Despite the fact it is relatively common, occurs around the world and can have a significant impact on a sufferer's functioning, levels of distress, and risk of suicide, the diagnosis is often missed. In this review, we outline the clinical features of BDD including as characterized in the newly published World Health Organization's International Classification of Diseases 11, review the prevalence of BDD within different settings, and highlight the reasons why BDD may be underdiagnosed even within psychiatric settings. We additionally review the cultural considerations for BDD and finally discuss the evidence-based treatment approaches for BDD, particularly the use of serotonin reuptake inhibitor medication and cognitive behavioral therapy.

Body image dissatisfaction in patients with inflammatory bowel disease: a systematic review protocol

BACKGROUND

Inflammatory bowel disease (IBD) is a debilitating chronic disease characterised by inflammation and ulceration of the gastrointestinal tract. It is associated with a range of debilitating symptoms and reduced quality of life. People living with IBD may also be at risk of body image dissatisfaction (BID). BID is a distorted and negative view of the physical self, which in turn can adversely affect mental health and quality of life. To date, there have been no systematic reviews of the evidence on BID in IBD patients. Therefore, the aim of this systematic review is to clarify the evidence base on BID in *IBD patients including (i) the tools used to measure BID, (ii) the prevalence and severity of BID, (iii) the risk factors associated with BID and (iv) the relationship between BID and quality of life.

METHODS

Bibliographic databases (EMBASE, MEDLINE, PsycINFO, Cochrane CENTRAL) will be searched using a sensitive search strategy aiming to identify any quantitative study reporting on body image in the context of IBD. This will be supplemented by searches of ongoing trials registers and checking of reference lists. Studies will be assessed for eligibility using predetermined selection criteria for each question. Data will be extracted using a predefined data extraction form, and risk of bias (quality) of included studies will be assessed based on checklists appropriate to the study designs identified. Key methodological steps will be undertaken in duplicate to minimise bias and error. Synthesis will be undertaken separately for the different systematic review sub-questions. Given the anticipated heterogeneity of evidence on each question, it is likely that synthesis will be mostly narrative.

DISCUSSION

To the best of our knowledge, this will be the first systematic review to collate the existing evidence on BID in IBD patients. Understanding the impact of BID, its relationship with quality of life, and which patients may be at greater risk, may ultimately lead to the development of interventions to prevent or treat BID and to better patient care. Any gaps in the identified evidence will help to inform the research agenda in this area.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO: (CRD42018060999).

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.

An Intensive Cognitive Behavioral Treatment for Body Dysmorphic Disorder

Body dysmorphic disorder affects 2.4% of the U.S. adult population, with the most common age of onset between 12 and 13 years. However, research in the area of adolescent BDD is minimal. This case study describes the intensive approach of treatment used for a 14-year-old female diagnosed with BDD. Treatment included an individualized course of cognitive behavioral therapy and exposure and response prevention. BDD symptoms decreased after 27 full-day sessions in an outpatient clinic. In addition, general levels of anxiety decreased and level of functioning increased. Tailoring standard treatments and utilizing developmentally appropriate techniques were significant factors for the adolescent’s success. Implications for future research and treatment are discussed.

Long-term effects of conservative treatment of Milwaukee brace on body image and mental health of patients with idiopathic scoliosis

We aimed to provide a complex assessment of adult females with adolescent idiopathic scoliosis (AIS) after a minimum of 23 years after completed Milwaukee brace treatment. In the present study, a comparison between healthy female and AIS patients’ perception of trunk disfigurement, self-image, mental health, pain level and everyday activity was made. Thirty AIS patients with a mean of 27.77 yrs (SD 3.30) after the treatment were included in the study. The control group consisted of 42 females, matching the age profile of the patient group. Study participants from both groups were examined using the same protocol, except for the radiological evaluation. Patients and healthy controls completed the Polish versions of the Scoliosis Research Society (SRS-22) and Spinal Appearance Questionnaire (SAQ). Patients additionally filled the Bad Sobberheim Stress Questionnaire-Deformity (BSSQ-Deformity) and Bad Sobberheim Stress Questionnaire-Brace (BSSQ-Brace). The study group’s SAQ results differ significantly in regard to the total score and all individual domains, indicating better functioning among healthy controls. Except for the General domain (p = 0.002), among the remaining subscales the study group’s results differed significantly at p<0.001. Considering SRS-22 results, it was revealed that the patient group scored higher, signaling better functioning with reference to pain level (p = 0.016), function/activity (p<0.001) and the total score (p<0.001). The findings add to the complexity of long-term effect evaluations of AIS, particularly amongst females treated with a Milwaukee brace. Long-term results were not conclusive in terms of nonverbal assessment of body image and emotional tension regarding the experiences of brace-wearing. Future patients can be reassured that scoliosis treated conservatively does not negatively affect everyday activity, pain level, childbearing and mental health. Subjects who declared to have psychological problems due to scoliosis had a bigger curve size after treatment and in this study than the other AIS patients.

Clinical Practice Guideline: Improving Nasal Form and Function after Rhinoplasty

Objective Rhinoplasty, a surgical procedure that alters the shape or appearance of the nose while preserving or enhancing the nasal airway, ranks among the most commonly performed cosmetic procedures in the United States, with >200,000 procedures reported in 2014. While it is difficult to calculate the exact economic burden incurred by rhinoplasty patients following surgery with or without complications, the average rhinoplasty procedure typically exceeds $4000. The costs incurred due to complications, infections, or revision surgery may include the cost of long-term antibiotics, hospitalization, or lost revenue from hours/days of missed work. The resultant psychological impact of rhinoplasty can also be significant. Furthermore, the health care burden from psychological pressures of nasal deformities/aesthetic shortcomings, surgical infections, surgical pain, side effects from antibiotics, and nasal packing materials must also be considered for these patients. Prior to this guideline, limited literature existed on standard care considerations for pre- and postsurgical management and for standard surgical practice to ensure optimal outcomes for patients undergoing rhinoplasty. The impetus for this guideline is to utilize current evidence-based medicine practices and data to build unanimity regarding the peri- and postoperative strategies to maximize patient safety and to optimize surgical results for patients. Purpose The primary purpose of this guideline is to provide evidence-based recommendations for clinicians who either perform rhinoplasty or are involved in the care of a rhinoplasty candidate, as well as to optimize patient care, promote effective diagnosis and therapy, and reduce harmful or unnecessary variations in care. The target audience is any clinician or individual, in any setting, involved in the management of these patients. The target patient population is all patients aged ≥15 years. The guideline is intended to focus on knowledge gaps, practice variations, and clinical concerns associated with this surgical procedure; it is not intended to be a comprehensive reference for improving nasal form and function after rhinoplasty. Recommendations in this guideline concerning education and counseling to the patient are also intended to include the caregiver if the patient is <18 years of age. Action Statements The Guideline Development Group made the following recommendations: (1) Clinicians should ask all patients seeking rhinoplasty about their motivations for surgery and their expectations for outcomes, should provide feedback on whether those expectations are a realistic goal of surgery, and should document this discussion in the medical record. (2) Clinicians should assess rhinoplasty candidates for comorbid conditions that could modify or contraindicate surgery, including obstructive sleep apnea, body dysmorphic disorder, bleeding disorders, or chronic use of topical vasoconstrictive intranasal drugs. (3) The surgeon, or the surgeon's designee, should evaluate the rhinoplasty candidate for nasal airway obstruction during the preoperative assessment. (4) The surgeon, or the surgeon's designee, should educate rhinoplasty candidates regarding what to expect after surgery, how surgery might affect the ability to breathe through the nose, potential complications of surgery, and the possible need for future nasal surgery. (5) The clinician, or the clinician's designee, should counsel rhinoplasty candidates with documented obstructive sleep apnea about the impact of surgery on nasal airway obstruction and how obstructive sleep apnea might affect perioperative management. (6) The surgeon, or the surgeon's designee, should educate rhinoplasty patients before surgery about strategies to manage discomfort after surgery. (7) Clinicians should document patients' satisfaction with their nasal appearance and with their nasal function at a minimum of 12 months after rhinoplasty. The Guideline Development Group made recommendations against certain actions: (1) When a surgeon, or the surgeon's designee, chooses to administer perioperative antibiotics for rhinoplasty, he or she should not routinely prescribe antibiotic therapy for a duration >24 hours after surgery. (2) Surgeons should not routinely place packing in the nasal cavity of rhinoplasty patients (with or without septoplasty) at the conclusion of surgery. The panel group made the following statement an option: (1) The surgeon, or the surgeon's designee, may administer perioperative systemic steroids to the rhinoplasty patient.

Prevalence and correlates of body dysmorphic disorder in a community sample of adolescents

OBJECTIVE

Body dysmorphic disorder typically begins in adolescence, yet little is known about the prevalence and correlates of the disorder in this age group. The current study aimed to explore the presenting features of adolescents meeting probable criteria for body dysmorphic disorder in a large community sample, and compare levels of comorbid psychopathology, quality of life and mental health service use between adolescents with probable body dysmorphic disorder and those without.

METHOD

Questionnaires were completed at school by 3149 adolescents: 63% male, aged 12-18 years ( M = 14.58). These assessed Diagnostic and Statistical Manual of Mental Disorders (4th ed.) body dysmorphic disorder criteria, past mental health service use and symptoms of body dysmorphic disorder, anxiety, depression, obsessive-compulsive disorder and eating disorders. In male participants, additional measures assessed quality of life, muscularity concerns, emotional symptoms, peer problems, conduct problems and hyperactivity.

RESULTS

The prevalence of probable body dysmorphic disorder was 1.7%; there was no sex difference in prevalence, but older adolescents reported higher prevalence than younger adolescents. Probable body dysmorphic disorder participants reported substantially elevated levels of psychopathology, quality of life impairment and mental health service use compared to non-body dysmorphic disorder participants.

CONCLUSIONS

The prevalence of body dysmorphic disorder in adolescents is similar to adult samples, and probable body dysmorphic disorder is associated with comorbidity, distress and functional impairment in a community sample. Further research is required to better understand the presentation of body dysmorphic disorder in adolescents, and to improve diagnosis and treatment.

Sex Differences in the Presentation of Body Dysmorphic Disorder in a Community Sample of Adolescents

The current study sought to explore sex differences in the presentation of probable full-syndrome and subthreshold body dysmorphic disorder (BDD) in adolescents from an Australian community sample. Specifically, it examined sex differences in the types of BDD symptoms endorsed, body areas of concern, and the association with elevated symptoms of comorbid disorders. In male participants, it also compared the presenting features of those with and without muscle dysmorphia. Of 3,149 adolescents assessed using self-report questionnaires, 162 (5.1%) reported probable BDD (57.4% male, M_age = 14.89 years, SD = 1.33, primarily from Oceanian or European cultural backgrounds). All participants completed measures of BDD symptoms; past mental health service use; and symptoms of anxiety, depression, obsessive-compulsive disorder, and eating disorders. Male participants completed additional measures of quality of life, drive for muscularity, hyperactivity, conduct disorder, peer problems, and emotional symptoms. Controlling for demographic variables that varied by sex, male and female participants reported similar BDD symptom severity, rates of most elevated comorbid symptoms, and mental health service use. Concerns regarding muscularity, breasts/nipples, and thighs differed by sex. Female participants were more likely than male participants to report elevated generalized anxiety symptoms. In male participants, muscle dysmorphia was not associated with greater severity across most measures. The presenting features of BDD were broadly similar in male and female participants, and in male participants with and without muscle dysmorphia. Future research should seek to increase mental health service use in adolescents with BDD and to improve rates of disorder detection in clinical settings.

Improving the Detection of Body Dysmorphic Disorder in Clinical Practice

The aim of this article is to raise awareness of the underdiagnosis of body dysmorphic disorder (BDD) in clinical practice and provide suggestions to overcome key barriers to BDD detection. Disclosure of BDD symptoms is uncommon during routine assessments but can be increased by asking specifically about such symptoms. When BDD symptoms are present, it is important to differentiate them from anxiety, depression, obsessive-compulsive disorder, and eating disorders, which may present with some similarities and are commonly comorbid with BDD. Assessment of BDD should be sensitive to issues of poor insight, elevated suicide risk, subthreshold BDD presentations, and the possibility of BDD by proxy. Furthermore, assessment should consider the potential impact of age, gender, ethnicity, and minor physical defects on the presentation of BDD. Improving the assessment of BDD in routine clinical practice will enhance disclosure, improve case conceptualization, and provide the opportunity to deliver appropriate treatment for this underdiagnosed and often serious disorder.

Body dysmorphic disorder in different settings: A systematic review and estimated weighted prevalence

Our aim was to systematically review the prevalence of body dysmorphic disorder (BDD) in a variety of settings. Weighted prevalence estimate and 95% confidence intervals in each study were calculated. The weighted prevalence of BDD in adults in the community was estimated to be 1.9%; in adolescents 2.2%; in student populations 3.3%; in adult psychiatric inpatients 7.4%; in adolescent psychiatric inpatients 7.4%; in adult psychiatric outpatients 5.8%; in general cosmetic surgery 13.2%; in rhinoplasty surgery 20.1%; in orthognathic surgery 11.2%; in orthodontics/cosmetic dentistry settings 5.2%; in dermatology outpatients 11.3%; in cosmetic dermatology outpatients 9.2%; and in acne dermatology clinics 11.1%. Women outnumbered men in the majority of settings but not in cosmetic or dermatological settings. BDD is common in some psychiatric and cosmetic settings but is poorly identified.

Stress exposure and generation: A conjoint longitudinal model of body dysmorphic symptoms, peer acceptance, popularity, and victimization

This study examined the bidirectional (conjoint) longitudinal pathways linking adolescents' body dysmorphic disorder (BDD) symptoms with self- and peer-reported social functioning. Participants were 367 Australian students (45.5% boys, mean age=12.01 years) who participated in two waves of a longitudinal study with a 12-month lag between assessments. Participants self-reported their symptoms characteristic of BDD, and perception of peer acceptance. Classmates reported who was popular and victimized in their grade, and rated their liking (acceptance) of their classmates. In support of both stress exposure and stress generation models, T1 victimization was significantly associated with more symptoms characteristic of BDD at T2 relative to T1, and higher symptom level at T1 was associated with lower perceptions of peer acceptance at T2 relative to T1. These results support the hypothesized bidirectional model, whereby adverse social experiences negatively impact symptoms characteristic of BDD over time, and symptoms also exacerbate low perceptions of peer-acceptance.

Suicidality in body dysmorphic disorder (BDD): A systematic review with meta-analysis

Although a considerable number of studies have indicated that the rates of suicidal thoughts and behaviors in Body Dysmorphic Disorder (BDD) are high, no systematic review has been undertaken to explore the strength and patterns of the relationship between suicidality and BDD. This is the first systematic review and meta-analysis which aimed to examine the association between BDD and suicidality and the mechanisms underlying suicidality in BDD. Searches of five bibliographic databases including Medline, PsychINFO, Embase, Web of Science and CINAHL, were conducted from inception to June 2015. Seventeen studies were included in the review. Meta-analyses were performed using random effect models to account for the high levels of heterogeneity in the data. A positive and statistically significant association was found between BDD and suicidality (OR=3.63, 95% CI=2.62 to 4.63). Subgroup analyses showed that BDD was associated with increased odds for both, suicide attempts (OR=3.30, 95% CI=2.18 to 4.43) and suicidal ideation (OR=2.57, 95% CI=1.44 to 3.69). The evidence concerning suicide deaths in BDD was scarce. BDD-specific factors and comorbid diagnoses of Axis I disorders were likely to worsen suicidality in BDD. However, the modest number, and the low methodological quality, of the studies included in this review suggest caution the interpretation of these findings.

Yale-Brown Obsessive Compulsive Scale modified for Body Dysmorphic Disorder (BDD-YBOCS): Brazilian Portuguese translation, cultural adaptation and validation

OBJECTIVE

To translate, culturally adapt, and validate a Brazilian Portuguese version of the Yale-Brown Obsessive Compulsive Scale modified for Body Dysmorphic Disorder (BDD-YBOCS).

METHODS

Ninety-three patients of both sexes seeking rhinoplasty were consecutively selected at the Plastic Surgery Outpatient Clinic of the Universidade Federal de São Paulo, Brazil, between May 2012 and March 2013. The BDD-YBOCS was translated into Brazilian Portuguese. Thirty patients participated in the cultural adaptation of the scale. The final version was tested for reliability in 20 patients, and for construct validity in 43 patients (correlation of the BDD-YBOCS with the Body Dysmorphic Disorder Examination [BDDE]).

RESULTS

Total Cronbach's alpha was 0.918. The BDD-YBOCS had excellent inter-rater (intra-class correlation coefficient [ICC] = 0.934; p < 0.001) and intra-rater reliability (ICC = 0.999; p < 0.001). Significant differences in BDD-YBOCS scores were found between patients with and without BDD symptoms (p < 0.001), and among patients with different levels of BDD severity (p < 0.001). A strong correlation (r = 0.781; p < 0.001) was observed between the BDDE and the BDD-YBOCS. The area under the receiver operating characteristic curve was 0.851, suggesting a very good accuracy for discriminating between presence and absence of BDD symptoms.

CONCLUSION

The Brazilian Portuguese version of the BDD-YBOCS is a reliable instrument, showing face, content and construct validity.

Prevalence of Body Dysmorphic Disorder Symptoms and Body Weight Concerns in Patients Seeking Abdominoplasty

BACKGROUND

Body dysmorphic disorder (BDD) is one of the most common psychiatric conditions found in patients seeking cosmetic surgery, and body contouring surgery is most frequently sought by patients with BDD.

OBJECTIVES

To estimate the prevalence and severity of BDD symptoms in patients seeking abdominoplasty.

METHODS

Ninety patients of both sexes were preoperatively divided into two groups: patients with BDD symptoms (n = 51) and those without BDD symptoms (n = 39) based both on the Body Dysmorphic Disorder Examination (BDDE) and clinical assessment. Patients in the BDD group were classified as having mild to moderate or severe symptoms, according to the BDDE. Body weight and shape concerns were assessed using the Body Shape Questionnaire (BSQ).

RESULTS

The prevalence of BDD symptoms was 57%. There were significant associations between BDD symptoms and degree of body dissatisfaction, level of preoccupation with physical appearance, and avoidance behaviors. Mild to moderate and severe symptoms of BDD were present in 41% and 59% of patients, respectively, in the BDD group. It was found that the more severe the symptoms of BDD, the higher the level of concern with body weight and shape (P < .001). Patients having distorted self-perception of body shape, or distorted comparative perception of body image were respectively 3.67 or 5.93 times more likely to show more severe symptoms of BDD than those with a more accurate perception.

CONCLUSIONS

Candidates for abdominoplasty had a high prevalence of BDD symptoms, and body weight and shape concerns were associated with increased symptom severity.

Prevalence of body dysmorphic disorder on a psychiatric inpatient ward and the value of a screening question

The aim of this study was to estimate the prevalence of body dysmorphic disorder (BDD) on an inpatient ward in the UK with a larger sample than previously studied and to investigate the value of a simple screening question during an assessment interview. Four hundred and thirty two consecutive admissions were screened for BDD on an adult psychiatric ward over a period of 13 months. Those who screened positive had a structured diagnostic interview for BDD. The prevalence of BDD was estimated to be 5.8% (C.I. 3.6-8.1%). Our screening question had a slightly low specificity (76.6%) for detecting BDD. The strength of this study was a larger sample size and narrower confidence interval than previous studies. The study adds to previous observations that BDD is poorly identified in psychiatric inpatients. BDD was identified predominantly in those presenting with depression, substance misuse or an anxiety disorder. The screening question could be improved by excluding those with weight or shape concerns. Missing the diagnosis is likely to lead to inappropriate treatment.

Assessing the factor structure of the Body Uneasiness Test (BUT) in an overweight and obese Croatian non-clinical sample

PURPOSE

The study objectives are to investigate the psychometric properties of the Body Uneasiness Test (BUT-A) in a general sample of overweight and obese persons in Croatia, to evaluate structure differences between men and women and to examine the relationship with other measures of body dissatisfaction as well as with objective body mass measure.

METHODS

This study included 320 adults (156 women and 164 men; aged between 20 and 71) with BMIs ranging from 24 to 48.83 kg/m(2).

RESULTS

The analysis confirmed a structural one-factor model for BUT-A. The one-factor model fits the data equally as well as the more complex five-factor model did and should be considered a more robust, parsimonious and adequate model. Female participants showed higher results (higher body uneasiness), but the importance of items is roughly comparable between genders. The BUT-A score significantly contributes to the prediction of general body dissatisfaction, even after gender and BMI are controlled. The multifaceted nature of the BUT-A might explain the relatively low measure of general body dissatisfaction in this sample. Congruent with previous studies, obese subjects expressed dissatisfaction with their body on the figure rating scale by selecting the ideal figure two units thinner than their current body figure. In overweight and obese men, body dissatisfaction is lower than in women.

CONCLUSION

The BUT-A can be a reliable one-dimensional tool for the assessment of body uneasiness in a wide range of samples, including obese individuals.

Severe growing-up phobia, a condition explained in a 14-year-old boy

We present the clinical case of a 14-year-old boy with gerascophobia or an excessive fear of aging, who felt his body development as a threat, to the point where he took extreme measures to stop or otherwise hide growth. He had a history of separation anxiety, sexual abuse, and suffering bullying. He presented with anxious and depressive symptoms and food restriction, criticized his body image, had negative feelings towards the maturation process, suffered at the thought of being rejected, and was preoccupied with certain physical characteristics. We conducted an analysis of biological, psychological, and environmental factors and their possible interactions and established treatment with psychotherapy and fluoxetine. Because of the favorable results, this approach could be considered a good option in such cases.

Why some patients are unhappy: part 2. Relationship of nasal shape and trauma history to surgical success

BACKGROUND

A previous report indicated that secondary rhinoplasty patients with normal preoperative noses displayed significantly higher prevalences of depression, demanding behavior, previous aesthetic operations, and confirmed trauma (abuse/neglect) histories than patients who originally had dorsal deformities or straight noses with functional symptoms. The authors hypothesized that abuse or neglect might also influence patient satisfaction and suggest screening criteria.

METHODS

One hundred secondary rhinoplasty patients stratified by their original nasal shapes were examined by bivariate analysis to determine the characteristics associated with surgical satisfaction. Mediation analysis established intervening factors between total surgery number and patients' perceived success. Random forests identified important patient attributes that predicted surgical success; logistic regression confirmed these effects.

RESULTS

Satisfied patients originally had dorsal humps, three or fewer previous operations, were not demanding or depressed, were not looking for perfect noses, and had no trauma histories. Dissatisfied patients originally had subjectively normal noses, more than three operations, were depressed, had demanding personalities, and had trauma histories. Patients who had undergone the most operations were most likely to request more surgery and least likely to be satisfied. A trauma (abuse/neglect) history was the most significant mediator between patient satisfaction and number of operations and the most prominent factor driving surgery in patients with milder deformities.

CONCLUSIONS

Potentially causative links exist between trauma (abuse/neglect), body image disorders, and obsessive plastic surgery. Body dysmorphic disorder may be a model of the disordered adaptation to abuse or neglect, a variant of posttraumatic stress disorder. Our satisfied and dissatisfied patients shared common characteristics and therefore may be identifiable preoperatively.

A review of body dysmorphic disorder and its presentation in different clinical settings

OBJECTIVE

Body dysmorphic disorder (BDD) is a relatively common psychiatric disorder characterized by preoccupations with perceived defects in physical appearance. This review aimed to explore epidemiology, clinical features, comorbidities, and treatment options for BDD in different clinical settings.

DATA SOURCE AND STUDY SELECTION

A search of the literature from 1970 to 2011 was performed using the MEDLINE search engine. English-language articles, with no restriction regarding the type of articles, were identified using the search terms body dysmorphic disorder, body dysmorphic disorder clinical settings, body dysmorphic disorder treatment, and body dysmorphic disorder & psychodermatology.

RESULTS

BDD occurs in 0.7% to 2.4% of community samples and 13% of psychiatric inpatients. Etiology is multifactorial, with recent findings indicating deficits in visual information processing. There is considerable overlap between BDD and obsessive-compulsive disorder (OCD) in symptom etiology and response to treatment, which has led to suggestions that BDD can be classified with anxiety disorders and OCD. A recent finding indicated genetic overlap between BDD and OCD. Over 60% of patients with BDD had a lifetime anxiety disorder, and 38% had social phobia, which tends to predate the onset of BDD. Studies reported a high level of comorbidity with depression and social phobia occurring in > 70% of patients with BDD. Individuals with BDD present frequently to dermatologists (about 9%-14% of dermatologic patients have BDD). BDD co-occurs with pathological skin picking in 26%-45% of cases. BDD currently has 2 variants: delusional and nondelusional, and both variants respond similarly to serotonin reuptake inhibitors (SRIs), which may have effect on obsessive thoughts and rituals. Cognitive-behavioral therapy has the best established treatment results.

CONCLUSIONS

A considerable overlap exists between BDD and other psychiatric disorders such as OCD, anxiety, and delusional disorder, and this comorbidity should be considered in evaluation, management, and long-term follow-up of the disorder. Individuals with BDD usually consult dermatologists and cosmetic surgeons rather than psychiatrists. Collaboration between different specialties (such as primary care, dermatology, cosmetic surgery, and psychiatry) is required for better treatment outcome.

Prospective Assessment of Scoliosis-Related Anxiety and Impression of Trunk Deformity in Female Adolescents Under Brace Treatment

The aim of this study is to make a prospective analysis of changes in anxiety levels and determining their associations with a longitudinal subjective assessment of trunk deformity in adolescent females with scoliosis, in relation to clinical, radiological and brace-related data. The study design was comprised of three questionnaire assessments, with the second and third evaluations taking place 6 and 12 months after the beginning of the study, respectively. 36 AIS females treated conservatively were asked to fill in the Polish versions of the Spinal Appearance Questionnaire (SAQ-pl) and the trait version of the Spielberger's Anxiety Inventory for Children (STAIC-trait). High anxiety was indicated in 16.6, 8.3 and 8.3% during the 1st, 2nd and 3rd evaluations. Patients' results differ in regards to the Curve domain; the discrepancies concern the 2nd and 3rd and the 1st and 3rd evaluations (p = 0.028 and p = 0.003, respectively). The only association between STAIC-trait and SAQ-pl regards Trunk shift in the 1st evaluation (rs = 0.48). The logistic regression revealed that the duration of brace-wearing in months has a statistically significant (p = 0.021) influence on the probability of diagnosing patients' low anxiety levels in the 2nd assessment. Special attention should be paid to patients' emotional reactions later on as brace-wearing continues as well as to the results which support the point that patients' perceptions of spinal deformity do not deteriorate with treatment time. Clinicians need to be aware how patients' appearance-specific cognitions might be associated with levels of emotional distress and relate to clinical and radiological, scoliosis-related data.

Body dysmorphic disorder in patients with an eating disorder: prevalence and characteristics

OBJECTIVE

Body dysmorphic disorder (BDD), an abnormal preoccupation with perceived defects in one or more body parts, and eating disorders (ED) share several essential clinical features, making it sometimes difficult to differentiate between the two disorders. The aims of this study were to assess the prevalence of BDD in patients with ED and to compare characteristics of ED patients with and without BDD.

METHOD

We measured dysmorphic appearance concerns and behaviors, ED symptoms, general psychopathology, and quality of life in 158 patients seeking treatment for ED.

RESULTS

Forty-five percent screened positive for BDD. Patients with both disorders (ED + BDD) had significantly more dysmorphic appearance concerns, had more psychopathology, and were dissatisfied with a larger number of body parts than patients with ED only. The differences remained significant even after correcting for severity of eating disorder psychopathology.

DISCUSSION

This finding suggests that BDD is a distinct comorbid disorder in almost half of the patients with ED. It is thus important to recognize and treat the manifestation of BDD in patients with both disorders. Given that the treatment of BDD is different from that of ED, it is important to recognize BDD.

Potential link between body dysmorphic disorder symptoms and alexithymia in an eating-disordered treatment-seeking sample

This study aimed to explore the manifestation of body dysmorphic disorder symptoms in a sample of people with eating disorders and to investigate possible associations between body dysmorphia and alexithymia. Forty patients currently seeking treatment for an eating disorder completed a battery of six measures assessing alexithymia, mood, eating behaviours, weight-related body image, body dysmorphia and non-weight related body image. Significant moderate positive correlations (Pearson's r) between selected variables were found, suggesting that participants with high levels of dysmorphic concern (imagined ugliness) have more difficulty with the affective elements of alexithymia, that is, identifying and describing feelings. When depression, eating attitudes, and weight-related body image concerns were controlled for, significant moderate positive correlations between this alexithymia factor and dysmorphic concerns remained present. An independent-samples t-test between eating-disordered participants with and without symptoms of body dysmorphic disorder (BDD) revealed significant group differences in difficulties identifying feelings. This pattern of results was replicated when the groups were identified on the basis of dysmorphic concerns, as opposed to BDD symptoms. This study highlights the associations between alexithymia and body dysmorphia that have not previously been demonstrated.

Correlates of quality of life and functional disability in individuals with body dysmorphic disorder

OBJECTIVE

Body dysmorphic disorder (BDD) is a chronic mental illness characterized by low quality of life and functional disability across multiple domains. Despite the clinical importance of understanding impairment in BDD, there has been little research examining the factors that contribute to these constructs. The present study was designed to examine sociodemographic and clinical correlates of quality of life and disability (work, social, and family) in a sample of individuals with moderately severe BDD symptoms.

METHOD

Participants completed an internet survey with questions about demographics, BDD phenomenology, treatment, and impairment. Only participants who completed all study measures and received a score≥16 on the 10-item Yale-Brown Obsessive Compulsive Scale, Modified for BDD (BDD-YBOCS), indicating the presence of clinical BDD symptoms, were included in the analysis (n=256). Multivariate regression with backwards variable selection was used to identify significant predictors of quality of life and functional disability, assessed with the Quality of Life Enjoyment and Satisfaction Scale-Short Form (QLESQ-SF) and the Sheehan Disability Scale (SDS), respectively.

RESULTS

BDD symptom severity was inversely associated with quality of life and directly associated with disability in all domains. After controlling statistically for BDD symptom severity, sociodemographic and clinical factors such as age, gender, ethnicity, marital status, insurance, body parts of concern, depression symptoms, and anxiety symptoms were significantly associated with impairment.

CONCLUSION

Results suggest a multidimensional nature of quality of life and functional disability and underscore the importance of developing holistic treatment strategies to address impairment in BDD.

Prevalence of body dysmorphic disorder in a German psychiatric inpatient sample

Body dysmorphic disorder (BDD) is a distressing or impairing preoccupation with an imagined or slight defect in appearance. Only a few studies have examined BDD prevalence in psychiatric settings. Prevalence rates vary widely and most studies have been conducted in outpatient samples. In the current study, we examined 155 adult psychiatric inpatients. Diagnostic criteria of BDD were assessed with the BDD module of the Structured Clinical Interview for DSM-IV. The prevalence of lifetime BDD was 2.6% (95% CI=0.1-5.1%). Currently 1.9% of the patients suffered from BDD (95% CI=0.0-4.0%). None of these patients were diagnosed with BDD on admission or during hospitalization. The BDD rates found in this study are considerably lower than lifetime and current prevalence rates reported by two other studies conducted in adult psychiatric inpatient settings (Grant et al., 2001; Conroy et al., 2008). The differences may be explained by divergent sample compositions and variation in diagnostic measures. The findings of the current study underline the need for further studies examining BDD prevalence in psychiatric settings and suggest using a combination of screening questionnaire and follow-up interview to diagnose BDD.

[Body dysmorphic disorder (BDD)]

OBJECTIVE

Body Dysmorphic Disorder (BDD) has replaced the old and ill-defined concept of dysmorphophobia since its introduction as a full-blown disorder in DSM-III-R in 1987. Since then, the body of knowledge on BDD has considerably increased. At the same time, cosmetic medicine and surgical procedures, for which the indications and outcomes of BDD should be taken into account, have become common. Hence, we decided to undertake a review of the literature on BDD aimed at French speaking practitioners.

METHOD

We searched Medline for the literature on BDD and dysmorphophobia in English and in French and made a critical examination of findings resulting from those studies where the methodology was sound.

RESULTS

BDD is frequent in the general population with a point prevalence between 1.7 and 2.4% and often severe. Delusive and non-delusive forms of BDD likely belong to the same entity and both respond to the same treatment. Serotonin reuptake inhibitors and cognitive behavioral therapies have demonstrated their efficacy in randomized controlled studies. Esthetic, medical and surgical treatments, which are very often sought after by BDD patients, have been shown to be ineffective and potentially harmful.

DISCUSSION

Our review confirms the progress in knowledge on BDD. The most interesting results concern clinical characteristics, epidemiology in the general population, and treatment. The prevalence of BDD in the general population should prompt every practitioner to take this disorder into account when faced with the increasing demand for medical and surgical cosmetic procedures. Nevertheless, further research is needed, particularly on the demand of non psychiatric treatments by BDD patients and the way medical or surgical specialists manage it.