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

Suicidal thoughts and behaviours in body dysmorphic disorder: Prevalence and correlates in a sample of mental health service users in the UK

BACKGROUND

Previous research indicates an association of body dysmorphic disorder (BDD) with suicidal thoughts and behaviours, but has largely relied on small cohorts drawn from specialist clinics.

METHODS

Anonymised health-records from the South London and Maudsley NHS Foundation Trust between 2007 and 2019 were systematically searched using the Clinical Record Interactive Search data system.

RESULTS

298 patients diagnosed with BDD between age 12 and 65 years were identified. 206 (69 %) had experienced lifetime suicidal ideation. 149 (50 %) had recorded lifetime acts of self-harm or suicide attempts, most commonly involving cutting and self-poisoning. Rates of self-harm/suicide attempts were similar in those diagnosed before or after 18 years. Comorbid depression was associated with suicidal ideation (OR: 4.26 95% CI 2.07-9.72). Additionally, comorbid depression, OCD and anxiety were all associated with self-harm/suicide attempts (OR: 1.94 95% CI 1.15-3.31, OR: 1.99 95% CI 1.09-3.73, and OR: 1.93 95% CI 1.09-3.45, respectively). The presence of two or more psychiatric comorbidities was associated with a significantly elevated likelihood of suicidal ideation (OR: 7.06 95% CI 2.80-21.7) and self-harm/suicide attempts (OR: 4.62 95% CI 2.32-9.62).

LIMITATIONS

It is likely that BDD was under-diagnosed in the cohort, and those identified may not be representative. Additionally, the frequency and detail with which suicidal thoughts and behaviours were assessed varied and may also represent underestimates.

CONCLUSIONS

Suicidal ideation and self-harm/suicide attempts are common among individuals with BDD accessing mental health services. Psychiatric comorbidity and suicidal ideation should be assessed in all BDD patients.

Exploring the Intersection of Body Dysmorphic Disorder (BDD) and Dermatological Conditions: A Narrative Review

This narrative literature review examined the intricate relationship between body dysmorphic disorder (BDD) and dermatological conditions, with a brief focus on those characterized by conspicuous skin irregularities such as acne vulgaris, psoriasis, and vitiligo. Highlighting the significant prevalence of BDD among individuals afflicted with dermatological issues, our analysis illuminated the profound psychological repercussions stemming from an exaggerated preoccupation with perceived skin imperfections. Through an exploration of the underlying BDD symptoms, we analyzed the complex dynamics between skin health and mental well-being, emphasizing the disorder's impact on patients' psychological and social functioning. This narrative review further investigated the consequential effects of BDD on essential aspects of dermatological treatment, including patient adherence to therapeutic regimens, overall quality of life (QOL), and the effectiveness of available treatments. In addition to presenting current therapeutic approaches, we advocate for the integration of psycho-dermatological interventions tailored to mitigate the dual burden of skin conditions and psychological distress. Future research directions proposed include longitudinal studies to assess the long-term effects of BDD on skin disease prognosis and psychosocial well-being, which aim to refine and optimize treatment modalities to contribute to a more holistic understanding of BDD within dermatological practice.

Maternal Accommodation of Adolescent Body Dysmorphic Disorder: Clinical Correlates and Association with Treatment Outcomes

Family accommodation (FA) is widely-recognised as an important clinical phenomenon in obsessive-compulsive disorder (OCD) and anxiety disorders, and is related to poorer treatment outcomes. However, FA has not been quantitatively explored in Body Dysmorphic Disorder (BDD). The aim of this study was to investigate the patterns and correlates of maternal accommodation in adolescent BDD, and its association with treatment outcomes. Participants were 131 adolescents with BDD and their mothers who completed the Family Accommodation Scale-Parent Report (FAS-PR) as part of routine clinical practice in a National and Specialist Service for Young People at the Maudsley Hospital, London. Seventy-six (58%) young people received specialist cognitive behavioural therapy for BDD and had post-treatment data available. All mothers engaged in at least one form of accommodation. Providing reassurance (98.5%) and assisting avoidance (88.5%) were the most commonly endorsed behaviours. Levels of accommodation were positively associated with clinician-rated BDD symptom severity (r = 0.18, p = 0.041) and maternal symptoms of anxiety, depression and stress (r = 0.41, p < 0.001), and negatively associated with child global functioning (r = -0.38, p < 0.001). Maternal accommodation did not predict treatment outcomes (β = 0.055, p > 0.05). The findings indicate that maternal accommodation is common and has important clinical correlates, but does not impact on treatment response. Consequently, the relationship between maternal accommodation and BDD symptoms may differ to that evidenced in paediatric OCD. Future longitudinal research exploring maternal and paternal accommodation, and assessing variables of interest at multiple time-points throughout treatment, is needed to advance understanding of the role of FA in adolescent BDD.

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.

Epidemiology of Body Dysmorphic Disorder and Appearance Preoccupation in Youth: Prevalence, Comorbidity and Psychosocial Impairment

OBJECTIVE

Little is known about how common and impairing body dysmorphic disorder (BDD) is in the general population of youth. We evaluated the prevalence, comorbidity, and psychosocial impairment associated with BDD and more broadly defined appearance preoccupation in young people.

METHOD

Data were drawn from the 2017 Mental Health of Children and Young People in England survey. BDD and psychiatric comorbidity were assessed in individuals 5 to 19 years of age (N = 7,654) according to DSM-5 criteria, using a clinician-rated standardized diagnostic assessment. Psychosocial impairment was measured with a quantitative scale and was indexed by reported self-harm and suicide attempts, as well as service use, assessed using structured interviews.

RESULTS

The point prevalence of BDD was 1.0% (95% CI = 0.8%-1.3%). BDD was significantly more common among adolescents than children (1.9 vs 0.1%; OR = 22.5, p < .001), and among female than male participants (1.8% vs 0.3%; OR = 7.3, p < .001). Approximately 70% of young people with BDD had psychiatric comorbidity, most commonly internalizing disorders. BDD was associated with self- and parent-reported psychosocial impairment, self-harm and suicide attempts, and service utilization. Appearance preoccupation was more common than full-syndrome BDD, but showed similar age and sex effects, patterns of comorbidity, and associated impairment.

CONCLUSION

BDD and appearance preoccupation are relatively common, especially among adolescent girls, and are associated with substantial co-occurring psychopathology, impairment, and risk. Improved screening is needed to increase detection and diagnosis of BDD, and to facilitate access to evidence-based treatment.

STUDY PREREGISTRATION INFORMATION

The epidemiology of body dysmorphic disorder the youth: prevalence, comorbidity and psychosocial impact; https://osf.io/g83jy.

The mediating effect of dysmorphic concern in the association between avoidant restrictive food intake disorder and suicidal ideation in adults

BACKGROUND

Reflecting on the existing literature on suicidal ideation and Avoidant/Restrictive Food Intake Disorder (ARFID), this article investigates the complex relationship between them, hypothesizing about the possibility of dysmorphic concerns, being a mediator linking ARFID to suicidal ideation.

METHODS

Using a snowball sampling approach, a survey was created on Google Forms and circulated across messaging applications and social media networks (WhatsApp, Instagram, Messenger). The sample involved 515 participants recruited between February and March 2023. The questionnaire included the following scales: Nine-items Avoidant/Restrictive Food Intake Disorder screen (NIAS), Dysmorphic Concern Questionnaire (DCQ), and Columbia-Suicide Severity Rating Scale (C-SSRS). When filling the questionnaire, respondents were warned that they can experience distress when answering certain questions and received information about mental health services. Five hundred fifteen adults participated in this study, with a mean age of 27.55 ± 10.92 years and 60.1% females.

RESULTS

After adjusting over potential confounders (i.e., age, education, marital status, and household crowding index), analyses showed that dysmorphic concerns fully mediated the association between avoidant restrictive eating and suicidal ideation. Higher avoidant restrictive eating was significantly associated with more dysmorphic concerns, and higher dysmorphic concerns were significantly associated with the presence of suicidal ideation. Finally, avoidant restrictive eating was not significantly associated with suicidal ideation.

CONCLUSION

This study highlights the potential indirect link between ARFID and suicidal ideation mediated by dysmorphic concerns. While no direct connection was observed between ARFID and suicidal ideation, the presence of dysmorphic concerns appeared to be a crucial factor in amplifying the risk of suicidal ideation in individuals with ARFID. This emphasizes the importance of addressing dysmorphic concerns alongside ARFID treatment to enhance mental health interventions and outcomes.

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.

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.

Psychological Autopsy in Small Penis Syndrome: Determining the Manner and Circumstance of Death Following a Vehicular Accident

Road traffic accidents and related deaths are on the rise, especially in developing countries. Even though uncommon and probably under-recognized, predisposing psychiatric states may be contributory, posing the question of whether these could be avoided. Psychological autopsy, despite not being performed routinely, might play a pivotal role in such instances, in reconstructing events leading to the catastrophe and determining the role played by the parties involved. The legal implications, such as the exoneration of the wrongly accused, might be substantial. This case report presents a death of a middle-aged South Asian male with strong history and evidence of small penis anxiety following a direct collision in a road traffic accident. It highlights the careful evaluation of the clinical history of the deceased by a psychological autopsy and reiterates the importance of the former in suspected cases.

Genomics of Obsessive-Compulsive Disorder and Related Disorders: What the Clinician Needs to Know

A wealth of evidence has shown that genetics plays a major role in susceptibility to obsessive-compulsive disorder (OCD) and all of its related disorders. Several large-scale, collaborative efforts using modern genomic methods are beginning to reveal the genetic architecture of these traits and identify long-sought risk genes. In this article, we summarize current OCD and related disorder genomic knowledge and explain how to communicate this information to patients and their families. The article concludes with a discussion of how genomic discovery in OCD and related disorders can inform our understanding of disease etiology and provide novel targets for therapeutic development.

Body-dysmorphic, hoarding, hair-pulling, and skin-picking symptoms in a large sample of adolescents

Few studies have investigated body-dysmorphic, hoarding, hair-pulling, and skin-picking symptoms in adolescents and how they relate to mental health, quality of life, suicide attempts, and non-suicidal self-harm. We used a quota sampling procedure and contacted 100 secondary centres in the Southeast of Spain, of which 34 participated in the study. A sample of 5,345 adolescents (12–18 years) completed dimensional measures of body-dysmorphic, hoarding, hair-pulling, and skin-picking symptoms. The proportion of adolescents with clinically significant symptoms within each symptom type was estimated and associations with other indicators of mental health examined. Clinically significant body-dysmorphic symptoms were reported by 3.7%, hoarding by 0.9%, hair-pulling by 0.7%, and skin-picking by 1.8%. Body-dysmorphic symptoms were more common in girls and in those over 14 years of age. Body-dysmorphic, hoarding, hair-pulling, and skin-picking symptoms were moderately to strongly associated with obsessive-compulsive symptoms, internalizing symptoms, externalizing symptoms, and poor quality of life. Those with significant body-dysmorphic, hoarding, hair-pulling, and skin-picking symptoms were much more likely to have attempted suicide and engaged in non-suicidal self-harm during the last twelve months than those without such symptoms. Body-dysmorphic symptoms showed the strongest associations with internalizing symptoms and poor quality of life. Limitations are the sole use of self-report and a sample from only two regions in Spain, but findings suggest that body-dysmorphic, hoarding, hair-pulling, and skin-picking symptoms are common and impairing during adolescence.

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.

Concurrent and prospective associations of obsessive-compulsive symptoms with suicidality in young adults: A genetically-informative study

BACKGROUND

Obsessive-compulsive disorder (OCD) has been linked with elevated risk of suicidality. However, most previous studies have been cross-sectional, and little is known about the aetiology of the association between obsessive-compulsive symptoms (OCS) and suicidality in young adults.

METHODS

Participants were members of the Child and Adolescent Twin Study in Sweden, at ages 18 (n = 9,162) and 24 (n = 3,466). Twins completed self-report measures, including assessment of OCS, suicidal ideation, and suicidal attempts. Logistic regression models tested concurrent and prospective associations of total OCS and OCS dimensions with suicidality, with and without adjustment for depression and anxiety symptoms. Genetic models tested the extent to which the main phenotypic associations were accounted for by genetic and environmental influences.

RESULTS

Total OCS were significantly associated with concurrent reports of suicidality at age 18 and 24, even when controlling for depressive and anxiety symptoms. Taboo obsessions (e.g., sexual and aggressive thoughts) were more robustly associated with suicidality than other OCS dimensions, and prospectively predicted suicidality symptoms over time, even when controlling for baseline suicide attempts. Genetic factors accounted for most of the concurrent and longitudinal covariance between OCS and suicidality, with substantial non-shared environmental influences.

LIMITATIONS

We relied on self-report measures and did not include diagnostic assessment of OCD.

CONCLUSIONS

OCS, particularly taboo obsessions, are associated with significantly elevated risk of suicidality in late adolescence and early adulthood. This relationship is explained by a combination of common genetic liability and non-shared environmental effects, suggesting that effective OCS treatment might reduce suicidality risk in this group.