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

Visual Perceptual Processing Abnormalities in Body Dysmorphic Disorder

Phenomenological observations of individuals with body dysmorphic disorder (BDD), coupled with evidence from neuropsychological, psychophysical, and neuroimaging studies, support a model of aberrant visual perception characterized by deficient global/holistic, enhanced detail/local processing, and selective visual-attentional biases. These features may contribute to the core symptomatology of distorted perception of their appearance, in addition to misinterpretation of others' facial expressions and poor insight regarding their misperceived appearance defects. Insights from visual processing studies can contribute to the development of novel interventions, such as perceptual retraining and non-invasive neuromodulation. However, much remains to be understood about visual perception in BDD. Future research should leverage brain imaging modalities with high temporal resolutions and employ study designs that induce conflicts in multisensory integration, thereby advancing our mechanistic understanding of distorted visual perception observed in BDD.

Anxiety Disorders: The Relationship between Insight and Metacognition

BACKGROUND

The exploration of metacognition in relation to anxiety has received considerable attention in recent decades. Research indicates that it plays a role in the development and maintenance of anxiety disorders while also providing benefits, including the ability to assess situations, modify behaviors, and make informed decisions.

SUMMARY

We propose that having an awareness of a disorder, also known as insight, is related to metacognition in anxiety. This relationship stems from the ability it provides individuals to recognize their mental state through reflection on personal experiences. We discuss the impact of insight and metacognition on decision-making, treatment-seeking behaviors, and coping strategy selection.

KEY MESSAGES

Understanding the concept of insight in anxiety disorders, as compared to other mental disorders like psychosis, requires exploring its complexities while carefully considering the balance of harms and benefits. While the medicalization of symptoms in psychosis is widely regarded as clearly beneficial, evaluating the role of insight in anxiety disorders demands a more nuanced understanding. Gaining a fuller perspective on patients' beliefs can impact their behaviors and decision-making. Clinicians can achieve this by encouraging active self-reflection to increase awareness, which includes evaluating both severity and impact on daily functioning. This also involves expressing experiences and exploring attributions of anxiety. This practical approach enables clinicians to understand engagement and treatment-seeking behaviors, allowing them to tailor treatment plans and develop effective coping and management strategies. Ultimately, this knowledge promotes a deeper comprehension of insight into anxiety disorders.

Body Dysmorphic Disorder in Women

Body dysmorphic disorder (BDD) consists of distressing or impairing preoccupation with perceived defects in physical appearance that are actually nonexistent or only slight. This common and often-severe disorder, which affects more women than men, frequently goes unrecognized. BDD is associated with marked impairment in functioning, poor quality of life, and high rates of suicidality. Most patients seek cosmetic treatment, which virtually never improves BDD symptoms. In contrast, serotonin-reuptake inhibitors, often at high doses, and cognitive behavioral therapy that is tailored to BDD's unique clinical features are often effective. This article provides a clinical overview of BDD, including BDD in women.

The association between social media use and body dysmorphic symptoms in young people

Introduction

Social media use (SMU) is highly prevalent amongst young people and previous research suggests an association with mental health problems, including poor body image. However, the potential relationship between SMU and body dysmorphic disorder (BDD) has received little attention. Furthermore, little is known about the factors that moderate the potential association between SMU and body dysmorphic symptoms. The current study tested the associations between three facets of SMU and body dysmorphic symptoms and explored perfectionism as a moderator in a non-clinical sample.

Method

Two-hundred and nine 16-18-year-olds (mean age = 16.5 years, 37% male) recruited from schools in London completed an online survey measuring aspects of SMU, including: frequency of image-and text-based SMU; motivations for SMU (appearance, popularity, connection or values and interests); and active and passive SMU. Participants additionally completed validated measures of body dysmorphic symptoms, perfectionism, and anxiety/depressive symptoms. Linear regression models tested the association of body dysmorphic symptoms with different facets of SMU, with and without adjustment for age, sex and anxiety/depressive symptoms.

Results

Frequency of use of image-based, but not text-based, platforms was significantly and positively associated with body dysmorphic symptoms, and this association remained significant in the adjusted models. Appearance-based motivation for SMU was the only motivator uniquely associated with body dysmorphic symptoms across the unadjusted and adjusted models. Passive, not active, SMU was associated with body dysmorphic symptoms in unadjusted models, but this association became non-significant in the adjusted models. Self-oriented perfectionism moderated the association between frequency of image-based SMU and body dysmorphic symptoms.

Discussion

Image-based SMU, and appearance-based motivations for SMU, are positively associated with body dysmorphic symptoms. Self-oriented perfectionism may amplify the relationship between SMU and body dysmorphic symptoms. Our findings highlight the importance of a nuanced approach to examining SMU, and the need for further research to determine whether specific facets of SMU contribute to the development and/or maintenance of body dysmorphic symptoms.

Repetitive Thoughts and Behaviors in Autism Spectrum Disorder: A Symptom-Based Framework for Novel Therapeutics

While the core symptoms of autism spectrum disorder include repetitive thoughts and repetitive behaviors, repetitive phenomena also occur in many other psychiatric disorders. Types of repetitive thoughts include preoccupations, ruminations, obsessions, overvalued ideas, and delusions. Types of repetitive behaviors include tics, stereotypies, compulsions, extrapyramidal symptoms, and automatisms. We provide a description of how to recognize and classify different types of repetitive thoughts and behaviors in autism spectrum disorder, providing clarity on which phenomena should be considered a core feature of autism spectrum disorder and which phenomena are indicative of a comorbid psychiatric disorder. Clinical features that can be used to differentiate types of repetitive thoughts include whether they are distressing and the degree of insight the individual has, while repetitive behaviors can be classified based on whether they are voluntary, goal-directed/purposeful, and rhythmic. We present the psychiatric differential diagnosis of repetitive phenomena within the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) framework. Careful clinical consideration of these transdiagnostic features of repetitive thoughts and behaviors can improve diagnostic accuracy and treatment outcomes, and influence future research.

Early response to cognitive behavioral therapy for body dysmorphic disorder as a predictor of outcomes

Individuals with body dysmorphic disorder (BDD) suffer from distressing or impairing preoccupations with perceived imperfections in their appearance. This often-chronic condition is associated with significant functional impairment and elevated rates of psychiatric comorbidity and morbidity, including depression, substance use disorders, and suicidality. Cognitive behavioral therapy (CBT) for BDD has been shown to be efficacious. However, this intervention is long (up to 24 weeks) relative to many manualized approaches for other related conditions, there is a significant shortage of clinicians trained in CBT for BDD, and some patients drop out of treatment and/or do not respond. Thus, there is great interest in understanding and predicting who is most likely to respond, to better allocate clinical resources. This secondary data analysis of participants enrolled in prior uncontrolled and controlled studies of CBT for BDD explored whether early response to CBT, operationalized as percentage change in symptom severity within the first four weeks and the first 12 weeks of this 24-week treatment, predicts clinical outcomes for patients with BDD (n = 90). The findings indicated that minimal early symptom change was not indicative of eventual non-response. This suggests that patients and clinicians should not be discouraged by limited early improvement but should instead continue with a full course of treatment before reevaluating progress and alternative interventions. Overall, the results support the view that treatment success is more likely if a longer CBT protocol is followed. More work is needed to understand mechanisms of change and thus match optimal interventions to patient characteristics.

Body Dysmorphic Symptoms in Youth with Obsessive-compulsive Disorder: Prevalence, Clinical Correlates, and Cognitive Behavioral Therapy Outcome

The aims of the study were to estimate the prevalence of body dysmorphic symptoms in a sample of children and adolescents with obsessive-compulsive disorder, possible clinical correlates and whether BDD symptoms predict poorer treatment outcomes after cognitive behavioral therapy. The study included 269 children and adolescents with OCD, aged 7-17 years, from Denmark, Sweden, and Norway, who were treated with 14 weekly sessions of manualized, exposure-based CBT. Twenty-one patients (7.8%) had BDD symptoms. BDD symptoms were associated with older age (p = 0.003) and a higher prevalence of comorbid anxiety disorders (p = 0.025). In addition, patients with BDD symptoms endorsed a greater number of OCD symptoms than did those without BDD symptoms. Having symptoms of BDD did not affect the CBT outcome on OCD. The results of the study suggest that CBT for OCD is equally effective for those with and without comorbid BDD symptoms.

Is the needle as risky as the knife? The prevalence and risks of body dysmorphic disorder in women undertaking minor cosmetic procedures

OBJECTIVES

Body dysmorphic disorder is commonly considered a contraindication for major cosmetic surgery, but whether body dysmorphic disorder relates to poorer outcomes from minor cosmetic treatment remains unknown. This study aimed to explore the prevalence of body dysmorphic disorder in clients seeking non-surgical cosmetic procedures and to examine whether body dysmorphic disorder clients are vulnerable in minor cosmetic settings. Vulnerability was explored in terms of psychological distress, unrealistic expectations and motivations for treatment outcome, and reduced satisfaction with past cosmetic procedures.

METHOD

A cross-sectional online survey was completed by 154 women seeking minor cosmetic procedures which included the Body Dysmorphic Disorder Questionnaire - Dermatology Version to screen for body dysmorphic disorder, and measures of cosmetic treatment motivation, expectations and satisfaction.

RESULTS

Roughly 25% of women in the current sample screened positive for a potential body dysmorphic disorder diagnosis. Participants with suspected body dysmorphic disorder demonstrated higher levels of psychological distress and more unrealistic expectations and motivations for cosmetic treatment, such as improving social or romantic relationships. However, body dysmorphic disorder participants reported similar levels of satisfaction with past minor cosmetic treatments to the non-body dysmorphic disorder group.

CONCLUSION

While the relationship between body dysmorphic disorder and treatment outcome warrants further investigation in prospective research tracking satisfaction and adverse reactions over time, this preliminary evidence suggests clients with suspected body dysmorphic disorder display several vulnerabilities in non-surgical cosmetic settings. Given the rapidly increasing accessibility of minor cosmetic procedures, further research is needed to determine their safety for clients with body dysmorphic disorder. Detection of body dysmorphic disorder in non-surgical cosmetic settings could facilitate earlier psychological intervention, promoting superior long-term outcomes.

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.

Knowledge and competency standards for specialized cognitive behavior therapy for adult obsessive-compulsive disorder

Obsessive-Compulsive Disorder (OCD) is a leading cause of disability world-wide (World Health Organization, 2008). Treatment of OCD is a specialized field whose aim is recovery from illness for as many patients as possible. The evidence-based psychotherapeutic treatment for OCD is specialized cognitive behavior therapy (CBT, NICE, 2005, Koran and Simpson, 2013). However, these treatments are not accessible to many sufferers around the world. Currently available guidelines for care are deemed to be essential but insufficient because of highly variable clinician knowledge and competencies specific to OCD. The phase two mandate of the 14 nation International OCD Accreditation Task Force (ATF) created by the Canadian Institute for Obsessive Compulsive Disorders is development of knowledge and competency standards for specialized treatments for OCD through the lifespan deemed by experts to be foundational to transformative change in this field. This paper presents knowledge and competency standards for specialized CBT for adult OCD developed to inform, advance, and offer a model for clinical practice and training for OCD. During upcoming ATF phases three and four criteria and processes for training in specialized treatments for OCD through the lifespan for certification (individuals) and accreditation (sites) will be developed based on the ATF standards.

Specialty knowledge and competency standards for pharmacotherapy for adult obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD) affects approximately one person in 40 and causes substantial suffering. Evidence-based treatments can benefit many; however, optimal treatment can be difficult to access. Diagnosis is frequently delayed, and pharmacological and psychotherapeutic interventions often fail to follow evidence-based guidelines. To ameliorate this distressing situation, the International OCD Accreditation Task Force of the Canadian Institute for Obsessive-Compulsive Disorders has developed knowledge and competency standards for specialized treatments for OCD through the lifespan. These are foundational to evidence-based practice and will form the basis for upcoming ATF development of certification/accreditation programs. Here, we present specialty standards for the pharmacological treatment of adult OCD. We emphasize the importance of integrating pharmacotherapy with clear diagnosis, appreciation of complicating factors, and evidence-based cognitive behavioral therapy. Clear evidence exists to inform first- and second-line pharmacological treatments. In disease refractory to these initial efforts, multiple strategies have been investigated, but the evidence is more equivocal. These standards summarize this limited evidence to give the specialist practitioner a solid basis on which to make difficult decisions in complex cases. It is hoped that further research will lead to development of a clear, multi-step treatment algorithm to support each step in clinical decision-making.

A Review of Motivational Interviewing in Cognitive Behavioral Therapy for Obsessive-Compulsive Disorder

Although cognitive behavioral therapy (CBT) is a highly effective treatment for individuals with obsessive-compulsive disorder (OCD), a portion people with OCD do not benefit fully from CBT due to ambivalence about participating in treatment, nonadherence to exposure exercises, and dropout. This paper reviews the promising evidence for motivational interviewing (MI) as a therapeutic approach that is well suited to address these issues and potentially improve treatment outcomes. It will also provide a discussion of MI processes that may enhance CBT for OCD which can foster a collaborative relationship that integrates a patient's own goals and values into exposure planning, helps resolve ambivalence or reluctance to engage in exposure exercises and builds and supports patients' intrinsic motivation to participate in treatment. The review will conclude with a case report describing the use of pre-CBT MI for an individual with OCD.

Executive functions and insight in OCD: a comparative study

BACKGROUND

Around 25 to 30% of patients with obsessive-compulsive disorder (OCD) do not respond to treatment. These patients have the longest duration of disease and the worst prognosis. Following years of research on this topic, insight has emerged as a potential explanation for this therapeutic resistance. Therefore, it has become important to characterize OCD patients with poor insight. Few studies have focused on the neuropsychological and cognitive characteristics of these patients.

METHODS

To help fill this gap, we divided 57 patients into two groups, one with good insight and the other with poor insight, assessed their neuropsychological functions-through a Rey's figure test, a California verbal learning test, a Toulouse-Piéron test and a Wisconsin Card Sorting Test (WCST)-and compared the results with those of a paired control group.

RESULTS

The statistical analysis, with a significance level of 95%, revealed differences in the executive function tests, and particularly in the WCST (p ≤ 0.001) and trail-making-test (TMT A/B) (p = 0.002).

CONCLUSIONS

These differences suggest that the neuropsychological profile of poor-insight patients is different from their good-insight counterparts, emphasize the role played by the executive functions in insight and highlights the need for more accurate neurocognitive research and treatment.

Family accommodation in pediatric body dysmorphic disorder: A qualitative study

Family accommodation (FA) is significant in a range of disorders, yet it has never been explored in body dysmorphic disorder (BDD). Interviews were conducted with five young people with BDD, five parents, and five clinicians to explore the types, impact, and purpose of FA in BDD. Every participant reported significant FA of BDD, and the types reported were broadly similar to those found in other disorders. Reassurance giving/seeking and engagement in rituals were the two most common forms of FA reported with funding products being the third. Unsurprisingly, the driver for FA was to reduce the young person's distress and risk. Every participant commented on the negative impact FA had, including the financial burden, social implications, emotional well-being of family members, relationships, and conflict within the family, yet all young people also thought there were positive aspects to FA. Findings are discussed in the context of the limitations of this study.

Rates of remission, sustained remission, and recurrence in a randomized controlled trial of cognitive behavioral therapy versus supportive psychotherapy for body dysmorphic disorder

BACKGROUND

Little data exist on remission rates following psychotherapy for body dysmorphic disorder (BDD).

METHODS

Using data from a large study of therapist-delivered cognitive behavior therapy (CBT) versus supportive psychotherapy (SPT) for BDD (N = 120), we estimated remission rates at treatment endpoint, and rates of delayed remission, sustained remission, and recurrence at 6-month follow-up. We also examined improvement in broader mental health outcomes among remitters.

RESULTS

Full or partial remission rates at end-of-treatment were significantly higher following CBT (68%) than SPT (42%). At 6-month follow-up, an additional 10% (CBT) and 14% (SPT) experienced delayed remission, 52% (CBT) and 27% (SPT) experienced sustained remission, and 20% (CBT) and 14% (SPT) experienced recurrence. Remission was never achieved by 18% (CBT) and 45% (SPT). Participants in remission at end-of-treatment experienced significant improvements in functional impairment, depression severity, BDD-related insight, and quality of life compared to nonremitters.

CONCLUSIONS

Full or partial remission rates are high following CBT for BDD and higher than after SPT.

Muscle dysmorphia: A systematic and meta-analytic review of the literature to assess diagnostic validity

OBJECTIVE

Although muscle dysmorphia (MD) is a new addition to DSM-5 as a specifier of body dysmorphic disorder (BDD), previous studies have treated MD as a stand-alone diagnosis. We aimed to assess the validity of MD as a stand-alone diagnosis via systematic and meta-analytic review of MD literature using both Robins and Guze criteria and additional criteria from Kendler.

METHOD

We performed a systematic search of ProQuest, PsycInfo, and PubMed databases for the period of January 1993 to October 2019 resulting in 40 papers to examine Robins and Guze's criteria (clinical picture) as well as those added by Kendler (antecedent validators; concurrent validators; predictive validators).

RESULTS

We identified two distinct symptomatic presentations of MD using cluster analysis, a behavioral type and cognitive/behavioral type. For examining the concurrent validators, quantitative meta-analyses differentiated MD populations from controls; however, results were inconclusive in delineating MD from existing disorders. For assessing antecedent and predictive validators, the symptomatic profiles, treatment response, and familial links for MD were similar to those for BDD and for eating disorders.

DISCUSSION

We found preliminary support for MD as a clinically valid presentation, but insufficient evidence to determine whether it is best categorized as a specifier of BDD or unique psychiatric condition.

Greater history of traumatic event exposure and PTSD associated with comorbid body dysmorphic disorder in a large OCD cohort

The present study examined whether or not there are differential rates of traumatic event exposure and presumed Post-Traumatic Stress Disorder (PTSD) between individuals with OCD without comorbid presumed BDD (OCD-Non-BDD) and individuals with OCD with comorbid presumed BDD (OCD+BDD) within a large cohort of OCD participants (N = 605). Individuals in the OCD+BDD group had significantly higher rates of endorsing at least one lifetime traumatic event and presumed PTSD than individuals with OCD-Non-BDD. Additionally, individuals in the OCD+BDD group with comorbid presumed PTSD had significantly higher rates of major depressive disorder (MDD) and presumed panic disorder (PD). A logistic regression analysis revealed that presumed PTSD significantly predicted the presence of BDD symptoms among individuals who experienced at least one lifetime traumatic event in our sample. These findings suggest that individuals in the OCD+BDD group were more likely to have experienced a traumatic event in their lives, to experience presumed PTSD, and to have MDD and presumed PD than individuals in the OCD-Non-BDD group. Clinical implications and possible mechanistic pathways from trauma exposure to OCD and BDD symptomatology are discussed.

Störungseinsicht bei körperdysmorpher Störung, Zwangsstörung und sozialer Angststörung

Hintergrund

Die körperdysmorphe Störung (KDS) geht mit einer geringen Störungseinsicht bis zu wahnhaft anmutenden Überzeugungen bezüglich wahrgenommener körperlicher Makel einher, die für andere nur leicht oder nicht sichtbar sind. Während die Einsicht bei der KDS bereits vielfach untersucht wurde und obwohl sie ein transdiagnostisch relevantes Merkmal ist, gibt es kaum vergleichende Studien.

Ziel der Arbeit

Es wird untersucht, inwiefern sich Personen mit einer KDS von Personen mit einer Zwangsstörung (ZS) und einer sozialen Angststörung (SAS) dimensional und kategorial hinsichtlich der Einsicht unterscheiden.

Material und Methode

Personen mit KDS (n = 36), ZS (n = 38) und SAS (n = 36) beantworteten diagnostische Interviews und Fragebogen. Die Einsicht wurde mithilfe eines teilstrukturierten Interviews, das verschiedene Facetten und Grade von Einsicht erfasst, beurteilt (Brown Assessment of Beliefs Scale).

Ergebnisse

In allen Gruppen lagen unterschiedliche Einsichtsgrade im gesamten Spektrum von exzellent bis fehlend vor. Bei den Betroffenen mit einer KDS entsprach der Gesamtmittelwert einer schlechten (M = 13,25, SD ± 6,32), bei Betroffenen mit einer SAS einer ausreichenden (M = 10,39, SD ± 5,70) und bei Betroffenen mit einer ZS einer guten Einsicht (M = 4,74, SD ± 5,49). Abgesehen von einer stärkeren Fixiertheit der Überzeugung bei KDS war die Einsicht bei KDS und SAS dimensional und kategorial nicht signifikant voneinander verschieden, jedoch bei beiden Störungen schlechter als bei ZS.

Diskussion

Die Ergebnisse bestätigen, dass die KDS mit geringer Einsicht einhergeht, dies jedoch fast gleichermaßen auf die SAS zutrifft. Die Störungseinsicht erscheint bei allen untersuchten Störungen relevant und sollte in der Psychotherapie von Beginn an diagnostisch und psychotherapeutisch berücksichtigt werden.

Overlap of obsessive-compulsive personality disorder and autism spectrum disorder traits among OCD outpatients: an exploratory study

Background: Whereas the phenomenology of obsessive-compulsive personality disorder (OCPD) shows similarities to that of obsessive compulsive and related disorders (OCRDs) as well as with autism spectrum disorder (ASD), the relationship between these disorders is poorly understood.Aims: Within a clinical sample, we aimed to investigate the distribution of OCD, OCPD and ASD symptoms and traits and their interrelationship, as well as to evaluate insight and treatment refractoriness.Methods: Consecutive adult OCD outpatients were assessed for OCPD traits (Compulsive Personality Assessment Scale (CPAS)), OCD symptoms (Yale-Brown Obsessive Compulsive Scale (Y-BOCS)), ASD traits (Autism Spectrum Quotient (AQ)), insight (Brown Assessment of Beliefs Scale (BABS)) and treatment resistance (clinical records). Those scoring highly on the AQ underwent a diagnostic interview for ASD.Results: Sixty-seven consenting individuals completed the CPAS, BABS and AQ, and 65 completed the Y-BOCS. Twenty-four patients (35.8%) were diagnosed with OCPD. Patients with OCPD were less likely to be employed (p=.04). They demonstrated elevated AQ scores (p=.004) and rates of ASD diagnosis (54.2%) (p <.001). OCPD traits (CPAS) showed a highly significant correlation with ASD traits (AQ) (p<.001), and no association with Y-BOCS, BABS or treatment resistance.Conclusions: In an OCD cohort limited by small size, OCPD associated strongly with unemployment and ASD, with implications for diagnosis, treatment and outcome.KEY POINTSClinicians should exercise a high level of vigilance for OCPD and ASD in patients presenting with obsessive compulsive symptoms.The presence of OCPD may indicate a likelihood of disabling ASD traits, including cognitive inflexibility, poor central coherence and poor social communication.These neuropsychological factors may require separate clinical intervention strategies.

Gazing at facial features increases dissociation and decreases attractiveness ratings in non-clinical females - A potential explanation for a common ritual in body dysmorphic disorder

Rituals, such as gazing at faces, are common in body dysmorphic disorder (BDD) and appear in cognitive-behavioral models as a maintaining factor. Rituals are also common in obsessive-compulsive disorder (OCD). In contrast to OCD, the proposed associations between rituals and intrusive thoughts/appearance preoccupation have not been empirically investigated for BDD. We examined if the assumed effect of gazing rituals on attractiveness ratings exists and if it is associated with dissociation. In an experiment, we asked N = 65 non-clinical females to focus on the nose of a photographed face at pre- and post-test. In between, participants gazed at the nose of either the same (relevant gazing) or another face (irrelevant gazing). We found increasing dissociation after gazing in both conditions and a differentially stronger decrease of attractiveness ratings in the relevant gazing condition. Our findings support the hypothesized effect of gazing rituals on attractiveness evaluation in cognitive-behavioral models for BDD.

Challenges and opportunities facing contemporary orthognathic surgery

Here, we provide a brief overview of the challenges, innovations and potential opportunities facing contemporary management of individuals requiring orthognathic care.

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.

The relationship between body dysmorphic disorder and obsessive-compulsive disorder: A systematic review of direct comparative studies

OBJECTIVE

Current nosology conceptualises body dysmorphic disorder as being related to obsessive-compulsive disorder, but the direct evidence to support this conceptualisation is mixed. In this systematic review, we aimed to provide an integrated overview of research that has directly compared body dysmorphic disorder and obsessive-compulsive disorder.

METHOD

The PubMed database was searched for empirical studies which had directly compared body dysmorphic disorder and obsessive-compulsive disorder groups across any subject matter. Of 379 records, 31 met inclusion criteria and were reviewed.

RESULTS

Evidence of similarities between body dysmorphic disorder and obsessive-compulsive disorder was identified for broad illness features, including age of onset, illness course, symptom severity and level of functional impairment, as well as high perfectionism and high fear of negative evaluation. However, insight was clearly worse in body dysmorphic disorder than obsessive-compulsive disorder, and preliminary data also suggested unique visual processing features, impaired facial affect recognition, increased social anxiety severity and overall greater social-affective dysregulation in body dysmorphic disorder relative to obsessive-compulsive disorder.

CONCLUSION

Limitations included a restricted number of studies overall, an absence of studies comparing biological parameters (e.g. neuroimaging), and the frequent inclusion of participants with comorbid body dysmorphic disorder and obsessive-compulsive disorder. Risks of interpreting common features as indications of shared underlying mechanisms are explored, and evidence of differences between the disorders are placed in the context of broader research findings. Overall, this review suggests that the current nosological status of body dysmorphic disorder is somewhat tenuous and requires further investigation, with particular focus on dimensional, biological and aetiological elements.

Olfactory reference syndrome symptoms in Chinese university students: Phenomenology, associated impairment, and clinical correlates

BACKGROUND

The present study aimed to explore the phenomenology, associated impairment, and clinical correlates of olfactory reference syndrome (ORS) symptoms in a Chinese university student sample, and establish estimated ORS prevalence.

METHODS

A total of 421 undergraduate students completed self-report measures assessing symptoms of ORS, obsessive-compulsive disorder, depression, anxiety, stress, taijin kyofushu, fear of negative evaluation, and ORS-related functional impairment.

RESULTS

Higher ORS symptom severity was moderately associated with poorer insight, greater avoidance, and higher ORS-related functional impairment. ORS severity was weakly associated with increased comorbid disorder symptoms, and was not associated with gender. Clinically significant ORS symptoms were present in 2.4% of the sample.

DISCUSSION

Collectively, these findings suggest that ORS symptoms are relatively distinct from other disorders in a non-clinical sample. Future studies are encouraged to further explore the phenomenology, etiology, neurobiology, and treatment of ORS in order to inform diagnosis and nosology.

Pharmacological Treatment of Body Dysmorphic Disorder

Body dysmorphic disorder is a challenging disorder that manifests as erroneously perceived flaws in one’s physical appearance and repetitive behaviors in response to appearance concerns. This disorder is also frequently comorbid with other psychiatric disorders, including major depressive disorder and autism spectrum disorder. It is currently understood to arise from a combination of biological, psychological, and environmental factors. Treatment of body dysmorphic disorder typically consists of a combination of pharmacotherapy and cognitive behavioral therapy. However, not all patients respond to treatment, and BDD symptoms remain even in those who do respond. This review outlines current pharmacological and neuromodulation treatments for body dysmorphic disorder and suggests directions for future studies of novel treatments such as augmentation with atypical antipsychotics and the use of intranasal oxytocin in cases of body dysmorphic disorder that show residual symptomatology even with tailored monotherapy. There is emerging evidence suggesting that non-invasive neurostimulatory techniques, such as repetitive transcranial magnetic stimulation, may be of value in treatment-resistant cases.

Insight in body dysmorphic disorder (BDD) relative to obsessive-compulsive disorder (OCD) and psychotic disorders: Revisiting this issue in light of DSM-5

INTRODUCTION

In DSM-5, body dysmorphic disorder (BDD) was reclassified under the obsessive-compulsive and related disorders (OCRDs), but little is known about the nature of BDD beliefs. This study aimed to compare level of insight in BDD and consider related implications for DSM-5 classification.

METHOD

Participants were 27 BDD, 19 obsessive-compulsive disorder (OCD), and 20 psychosis (SZ) participants as well as 42 non-clinical controls (NC), who completed the Brown Assessment of Beliefs Scale (BABS) and Peters Delusions Inventory (PDI).

RESULTS

For total (and most individual) BABS items, BDD and SZ participants scored significantly higher than OCD and NC participants. On the PDI, there were significant group differences in number of questions endorsed, with clinical groups scoring significantly higher than the NC group on dimensions of distress and preoccupation, but not conviction.

CONCLUSION

These findings suggest appearance-related concerns in BDD somewhat resemble delusions seen in psychosis (and not OCD), and convey important nosological and therapeutic implications.

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

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

Treatment Modifications and Suggestions to Address Visual Abnormalities in Body Dysmorphic Disorder

Recent psychophysical and neurocognitive findings implicate abnormal visual processing for a range of stimuli in body dysmorphic disorder (BDD); such abnormalities differentiate BDD from other mental health disorders. Current treatments most commonly involve cognitive behavior therapy with or without accompanying antidepressant medications. These are moderately successful yet appear to overlook the core phenomenological aspect of abnormal perception in BDD. The following text summarizes the current literature of perceptual abnormalities within BDD and how these findings may be applied and incorporated into treatment options. Possible modifications of cognitive behavioral therapy (CBT) based on the widespread visual abnormalities within BDD include making perceptual mirror retraining a compulsory component of therapy and implementing self-exposure tasks within exposure and response prevention. Alternative options such as a visual training program to remediate visual abnormalities across a range of visual stimuli are also explored, which may be included as an adjunctive treatment alongside CBT.

Health anxiety in obsessive compulsive disorder and obsessive compulsive symptoms in severe health anxiety: An investigation of symptom profiles

Severe health anxiety (SHA) shares features with obsessive-compulsive disorder (OCD) and in recent years there has been a debate as to whether the two disorders may represent two facets of the same condition. Few studies have however investigated the overlap and differences in symptom profiles between the disorders. The primary aim of the present study was to investigate these aspects using one sample of participants with a principal diagnosis of SHA and one sample of participants with a principal OCD diagnosis. The second aim was to examine differences in improvement trajectories on measures of health anxiety and OCD symptoms in patients with SHA receiving treatment with exposure and response prevention. We compared persons participating in clinical trials with a principal diagnosis of SHA (N=290) to persons with a principal diagnosis of OCD (n=95) on measures of health anxiety, OCD symptoms, and depressive symptoms. A subsample of SHA participants (n=99) received exposure and response prevention (ERP) for SHA over 12 weeks and was assessed at baseline and post-treatment. The results showed large and significant differences between SHA and OCD patients on measures of health anxiety (ds=2.99-3.09) and OCD symptoms (ds=1.64-2.14), while they had equivalent levels of depressive symptoms (d=0.19, 95% CI [-0.04, 0.43]). In the SHA sample 7.6% had comorbid OCD, and in the OCD sample 9.5% had SHA. For participants with a principal diagnosis of SHA, ERP led to large reductions of health anxiety, but effects on OCD symptoms were small to moderate. Among participants with comorbid OCD, effect sizes were large on measures of health anxiety and moderate to large on OCD measures. We conclude that SHA and OCD are separate psychiatric disorders with limited overlap in symptom profiles.

Classification of body dysmorphic disorder - what is the advantage of the new DSM-5 criteria?

OBJECTIVE

In DSM-5 the diagnosis of body dysmorphic disorder (BDD) has been subjected to two important changes: Firstly, BDD has been assigned to the category of obsessive-compulsive and related disorders. Secondly, a new criterion has been defined requiring the presence of repetitive behaviors or mental acts in response to appearance concerns. The aims of this study were to report the prevalence rates of BDD based on a DSM-5 diagnosis, and to evaluate the impact of the recently introduced DSM-5 criteria for BDD by comparing the prevalence rates (DSM-5 vs.

DSM-IV) METHODS

BDD-criteria (DSM-IV/DSM-5), dysmorphic concerns, and depressive symptoms, were assessed in a representative sample of the German general population (N=2129, aged 18-65years).

RESULTS

The association between BDD case identification based on DSM-IV and DSM-5 was strong (Phi=.95, p<.001), although point prevalence of BDD according to DSM-5 was slightly lower (2.9%, n=62 vs. 3.2%, n=68). Approximately one third of the identified BDD (DSM-5) cases reported time-consuming behavioral acts in response to appearance concerns. In detail, 0.8% of the German general population fulfilled the BDD criteria and reported repetitive acts of at least one hour/day.

CONCLUSIONS

The revised criteria of BDD in DSM-5 do not seem to have an impact on prevalence rates. However, the recently added B-criterion reflects more precisely the clinical symptoms of BDD, and may be useful for distinguishing between various severity levels related to repetitive behaviors/mental acts.

Comorbidity between obsessive-compulsive disorder and body dysmorphic disorder: prevalence, explanatory theories, and clinical characterization

BACKGROUND

With the advent of the fifth edition of Diagnostic and Statistical Manual of Mental Disorders, body dysmorphic disorder (BDD) has been subsumed into the obsessive-compulsive disorders and related disorders (OCDRD) category.

OBJECTIVE

We aimed to determine the empirical evidence regarding the potential relationship between BDD and obsessive-compulsive disorder (OCD) based on the prevalence data, etiopathogenic pathways, and clinical characterization of patients with both disorders.

METHOD

A comprehensive search of databases (PubMed and PsycINFO) was performed. Published manuscripts between 1985 and May 2015 were identified. Overall, 53 studies fulfilled inclusion criteria.

RESULTS

Lifetime comorbidity rates of BDD-OCD are almost three times higher in samples with a primary diagnosis of BDD than those with primary OCD (27.5% vs 10.4%). However, other mental disorders, such as social phobia or major mood depression, are more likely among both types of psychiatric samples. Empirical evidence regarding the etiopathogenic pathways for BDD-OCD comorbidity is still inconclusive, whether concerning common shared features or one disorder as a risk factor for the other. Specifically, current findings concerning third variables show more divergences than similarities when comparing both disorders. Preliminary data on the clinical characterization of the patients with BDD and OCD indicate that the deleterious clinical impact of BDD in OCD patients is greater than vice versa.

CONCLUSION

Despite the recent inclusion of BDD within the OCDRD, data from comparative studies between BDD and OCD need further evidence for supporting this nosological approach. To better define this issue, comparative studies between BDD, OCD, and social phobia should be carried out.

A study of poor insight in social anxiety disorder

We investigated levels of insight among patients with Social Anxiety Disorder (SAD) as compared to patients with Obsessive-Compulsive Disorder (OCD) and evaluated whether levels of insight in SAD were related to specific sociodemographic and/or clinical features. Thirty-seven SAD patients and 51 OCD patients attending a tertiary obsessive-compulsive and anxiety disorders clinic were assessed with a sociodemographic and clinical questionnaire, a structured diagnostic interview, the Brown Assessment of Beliefs Scale (BABS), the Social Phobia Inventory (SPIN), the Beck Depression Inventory (BDI), the Sheehan Disability Scale (SDS), and the Treatment Adherence Survey-patient version (TAS-P). According to the BABS, SAD patients exhibited insight levels that were as low as those exhibited by OCD patients, with up to 29.7% of them being described as "poor insight" SAD. Although poor insight SAD patients were more frequently married, less depressed and displayed a statistical trend towards greater rates of early drop-out from cognitive-behavioral therapy, their insight levels were not associated with other variables of interest, including sex, age, employment, age at onset, duration of illness, associated psychiatric disorders, SPIN and SDS scores. Patients with poor insight SAD might perceive their symptoms as being less distressful and thus report fewer depressive symptoms and high rates of treatment non-adherence.

The German version of the Brown Assessment of Beliefs Scale (BABS): Development and evaluation of its psychometric properties

Lack of insight and delusional thinking are hallmarks of a series of psychological disorders such as psychotic disorders and body dysmorphic disorder (BDD). The purpose of the present study was to evaluate the German version of the clinician-administered Brown Assessment of Beliefs Scale (BABS; Am J Psychiatry 1998;155:e102-e108), which consists of 7 items assessing the degree of delusionality in the individual's disorder-related belief (e.g., "The person behind me is staring at me", "My nose looks disgusting"). Specifically, the original BABS was translated and back-translated according to established translation guidelines and administered in 70 individuals diagnosed with BDD. Internal consistency as well as convergent and divergent validity was high, suggesting that the German version of the BABS is a reliable and valid instrument to assess delusional thinking in psychological disorders such as BDD.

Phenomenology of OCD: lessons from a large multicenter study and implications for ICD-11

This study aimed to investigate the phenomenology of obsessive-compulsive disorder (OCD), addressing specific questions about the nature of obsessions and compulsions, and to contribute to the World Health Organization's (WHO) revision of OCD diagnostic guidelines. Data from 1001 patients from the Brazilian Research Consortium on Obsessive-Compulsive Spectrum Disorders were used. Patients were evaluated by trained clinicians using validated instruments, including the Dimensional Yale-Brown Obsessive-Compulsive Scale, the University of Sao Paulo Sensory Phenomena Scale, and the Brown Assessment of Beliefs Scale. The aims were to compare the types of sensory phenomena (SP, subjective experiences that precede or accompany compulsions) in OCD patients with and without tic disorders and to determine the frequency of mental compulsions, the co-occurrence of obsessions and compulsions, and the range of insight. SP were common in the whole sample, but patients with tic disorders were more likely to have physical sensations and urges only. Mental compulsions occurred in the majority of OCD patients. It was extremely rare for OCD patients to have obsessions without compulsions. A wide range of insight into OCD beliefs was observed, with a small subset presenting no insight. The data generated from this large sample will help practicing clinicians appreciate the full range of OCD symptoms and confirm prior studies in smaller samples the degree to which insight varies. These findings also support specific revisions to the WHO's diagnostic guidelines for OCD, such as describing sensory phenomena, mental compulsions and level of insight, so that the world-wide recognition of this disabling disorder is increased.

Body dysmorphic disorder

Body dysmorphic disorder (BDD) can be a severe and often debilitating psychiatric disorder that has been largely under-recognized and underdiagnosed. Pharmacologic and nonpharmacologic treatment options are available but limited. This review aims to provide an updated overview of the psychopathology and epidemiology of BDD, with an emphasis on current pharmacologic and nonpharmacologic treatment options for BDD.

The impact of comorbid body dysmorphic disorder on the response to sequential pharmacological trials for obsessive-compulsive disorder

Our aim was to investigate the impact of comorbid body dysmorphic disorder (BDD) on the response to sequential pharmacological trials in adult obsessive-compulsive disorder (OCD) patients. The sequential trial initially involved fluoxetine monotherapy followed by one of three randomized, add-on strategies: placebo, clomipramine or quetiapine. We included 138 patients in the initial phase of fluoxetine, up to 80 mg or the maximum tolerated dosage, for 12 weeks. We invited 70 non-responders to participate in the add-on trial; as 54 accepted, we allocated 18 to each treatment group and followed them for an additional 12 weeks. To evaluate the combined effects of sex, age, age at onset, initial severity, type of augmentation and BDD on the response to sequential treatments, we constructed a model using generalized estimating equations (GEE). Of the 39 patients who completed the study (OCD-BDD, n = 13; OCD-non-BDD, n = 26), the OCD-BDD patients were less likely to be classified as responders than the OCD-non-BDD patients (Pearson Chi-Square = 4.4; p = 0.036). In the GEE model, BDD was not significantly associated with a worse response to sequential treatments (z-robust = 1.77; p = 0.07). The predictive potential of BDD regarding sequential treatment strategies for OCD did not survive when the analyses were controlled for other clinical characteristics.

DSM-5 obsessive-compulsive and related disorders: clinical implications of new criteria

For the publication of DSM-5, obsessive-compulsive disorder (OCD) was the subject of significant revisions to its classification and diagnostic criteria. One of these significant changes was the placement of OCD in a new category, "Obsessive-Compulsive and Related Disorders (OCRDs)," which also includes body dysmorphic disorder (BDD), trichotillomania (hair-pulling disorder), excoriation (skin-picking) disorder, hoarding disorder, substance/medication-induced OCRD, OCRD due to another medical condition, and other specified OCRDs. Changes in the diagnostic criteria and grouping of these disorders may have significant clinical implications, and will be reviewed in this article.

Insight in adults with obsessive-compulsive disorder

The present study examined the clinical correlates of insight among adults with obsessive-compulsive disorder (OCD). One hundred and thirty treatment-seeking adults with a primary diagnosis of OCD, aged 18 to 68 years (mean 31.4 years) participated. Measures of clinical severity, obsessive-compulsive symptom dimensions, anxiety symptoms, depressive symptoms, and ability to resist and control OCD symptoms were obtained. Results indicated that poor insight was positively related to greater OCD symptom severity and poorer ability to resist and control OCD symptoms; this pattern of associations held when insight was examined continuously and categorically (i.e., high versus low insight). Insight was generally not associated with other clinical characteristics, except for a relationship with mental neutralizing behaviors. Insight did not mediate the relationship between the ability to resist and control OCD symptoms and obsessive-compulsive symptom severity. Overall, this study provides further information into the nature and role of insight in adults with OCD.

Spatial behavior reflects the mental disorder in OCD patients with and without comorbid schizophrenia

OBJECTIVE

Resolving the entangled nosological dilemma of whether obsessive-compulsive disorder (OCD) with and without schizophrenia (schizo-OCD and OCD, respectively) are two independent entities or whether schizo-OCD is a combined product of its parent disorders.

METHODS

Studying motor activity in OCD and in schizo-OCD patients. Performance of the patients was compared with the performance of the same motor task by a matching control individual.

RESULTS

Behavior in both schizo-OCD and OCD patients differed from controls in the excessive repetition and addition of acts, thus validating an identical OC facet. However, there was a significant difference in spatial behavior. Schizo-OCD patients traveled over a greater area with less focused activity as typical to schizophrenia patients and in contrast to OCD patients, who were more focused and traveled less in a confined area. While schizo-OCD and OCD patients share most of the OC ritualistic attributes, they differ in the greater spread of activity in schizo-OCD, which is related to schizophrenia disorder.

DISCUSSION

It is suggested that the finding on difference in spatial behavior is a reflection of the mental differences between OCD and schizophrenia. In other words, this could be an overt and observable manifestation of the mental state, and therefore may facilitate the nosology of OC spectrum disorders and OCD.

CONCLUSION

It seems as if both the OCD patients' focus on specific thoughts, and the contrasting wandering thoughts of schizophrenia patients, are reflected in the focused activity of the former and wandering from one place to the next of the latter.

Delusional versus nondelusional body dysmorphic disorder: recommendations for DSM-5

The core feature of body dysmorphic disorder (BDD) is distressing or impairing preoccupation with nonexistent or slight defects in one's physical appearance. BDD beliefs are characterized by varying degrees of insight, ranging from good (ie, recognition that one's BDD beliefs are not true) through "absent insight/delusional" beliefs (ie, complete conviction that one's BDD beliefs are true). The Diagnostic and Statistical Manual of Mental Disorders, 3rd ed., rev. (DSM-III-R) and The Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV) classified BDD's nondelusional form in the somatoform section of the manual and its delusional form in the psychosis section, as a type of delusional disorder, somatic type (although DSM-IV allowed double-coding of delusional BDD as both a psychotic disorder and BDD). However, little or no evidence on this issue was available when these editions were published. In this article, we review the classification of BDD's delusional and nondelusional variants in earlier editions of DSM and the limitations of their approaches. We then review empirical evidence on this topic, which has become available since DSM-IV was developed. Available evidence indicates that across a range of validators, BDD's delusional and nondelusional variants have many more similarities than differences, including response to pharmacotherapy. Based on these data, we propose that BDD's delusional and nondelusional forms be classified as the same disorder and that BDD's diagnostic criteria include an insight specifier that spans a range of insight, including absent insight/delusional BDD beliefs. We hope that this recommendation will improve care for patients with this common and often-severe disorder. This increased understanding of BDD may also have implications for other disorders that have an "absent insight/delusional" form.

Insight impairment in body image disorders: delusionality and overvalued ideas in anorexia nervosa versus body dysmorphic disorder

The two body image disorders anorexia nervosa (AN) and body dysmorphic disorder (BDD) share many similarities. Delusionality in BDD has recently gained increased attention, as the new DSM-5 criteria for BDD include an insight specifier. However, delusionalilty in AN has rarely been examined. We evaluated the delusionality of appearance-related beliefs in AN (n=19) vs. BDD (n=22) via structured interview. Participants also completed measures of disorder-specific psychopathology and body image. Compared to those with AN, individuals with BDD exhibited significantly greater delusionality on a dimensional scale (p=0.0014, d=1.07), and were more likely to meet dichotomous criteria for delusional beliefs (p=0.021, V=0.36). In AN, delusionality was associated specifically with shape concerns and drive for thinness; in BDD, delusionality was related to the severity of BDD symptoms (all p<0.05). Delusionality of appearance beliefs is present in individuals with AN, but is less pronounced than in BDD. Nevertheless, as high delusionality might predict poor treatment outcome in AN, treatment strategies that were originally developed to address delusionality in BDD might be modified for AN.

Symmetry Concerns as a Symptom of Body Dysmorphic Disorder

Symmetry obsessions are a common symptom of obsessive-compulsive disorder (OCD) and have several demographic and clinical correlates. Appearance-related symmetry concerns appear common in body dysmorphic disorder (BDD); however, no published studies have examined this topic. This study examined the clinical features, prevalence, and correlates of symmetry concerns involving physical appearance in two BDD samples (N=160 and N=115). More than 25% of participants in each sample reported symmetry concerns for a body part with which they were preoccupied (total of 18 body parts in sample 1 and 18 in sample 2). In sample 1, BDD participants with appearance-related symmetry concerns were older than those without appearance-related symmetry concerns. In sample 2, those with appearance-related symmetry concerns reported poorer mental health-related quality of life, were more likely to have experienced lifetime suicidal ideation, had better BDD-related insight, and were less likely to have a lifetime eating disorder. In both samples, participants with appearance-related symmetry concerns were more likely to have lifetime OCD but not OCD-related symmetry obsessions. Thus, symmetry is a common appearance concern in BDD that is associated with comorbid OCD but not with OCD symmetry concerns specifically, suggesting that symmetry concerns may have a different mechanism/pathophysiology in BDD versus OCD.

Psychometric evaluation of the Brown Assessment of Beliefs Scale in body dysmorphic disorder

The Brown Assessment of Beliefs Scale (BABS) is a widely used measure that assesses insight/delusionality-an important dimension of psychopathology-both dimensionally and categorically (e.g., delusional versus nondelusional). The BABS has been shown to have good psychometric properties in a number of disorders, but sample sizes were small. In the present study, 327 subjects with body dysmorphic disorder (BDD) were interviewed with the BABS to assess insight regarding appearance beliefs. Other measures were administered. Intraclass correlation coefficients demonstrated excellent interrater reliability and test-retest reliability; internal consistency was strong. Principal components factor analysis identified one factor accounting for 60% of the variance. Analyses with measures of severity of BDD, depressive symptoms, and general psychopathology indicated good discriminant validity. Among the treated subjects, the BABS was sensitive to change but not identical to improvement in symptom severity. These findings provide further evidence that the BABS is a reliable and valid measure of insight/delusionality.