Effectiveness of Multimodal Treatment for Young People With Body Dysmorphic Disorder in Two Specialist Clinics

Body dysmorphic disorder (BDD) typically originates in adolescence and is associated with considerable adversity. Evidence-based treatments exist but research on clinical outcomes in naturalistic settings is extremely scarce. We evaluated the short- and long-term outcomes of a large cohort of adolescents with BDD receiving specialist multimodal treatment and examined predictors of symptom improvement. We followed 140 young people (age range 10-18) with a diagnosis of BDD treated at two national and specialist outpatient clinics in Stockholm, Sweden (n = 96) and London, England (n = 44), between January 2015 and April 2021. Participants received multimodal treatment consisting of cognitive behavior therapy and, in 72% of cases, medication (primarily selective serotonin reuptake inhibitors). Data were collected at baseline, posttreatment, and 3, 6, and 12 months after treatment.The primary outcome measure was the clinician-rated Yale-Brown Obsessive-Compulsive Scale Modified for BDD, Adolescent version (BDD-YBOCS-A). Secondary outcomes included self-reported measures of BDD symptoms, depressive symptoms, and global functioning. Mixed-effects regression models showed that BDD-YBOCS-A scores decreased significantly from baseline to posttreatment (coefficient [95% confidence interval] = -16.33 [-17.90 to -14.76], p<0.001; within-group effect size (Cohen's d) = 2.08 (95% confidence interval, 1.81 to 2.35). At the end of the treatment, 79% of the participants were classified as responders and 59% as full or partial remitters. BDD symptoms continued to improve throughout the follow-up. Improvement was also seen on all secondary outcome measures. Linear regression models identified baseline BDD symptom severity as a predictor of treatment outcome at posttreatment, but no consistent predictors were found at the 12-month follow-up. To conclude, multimodal treatment for adolescent BDD is effective in both the short- and long-term when provided flexibly within a specialist setting. Considering the high personal and societal costs of BDD, specialist care should be made more widely available.

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.

Prevalence and impact of insomnia in children and adolescents with body dysmorphic disorder undergoing multimodal specialist treatment

Pediatric body dysmorphic disorder (BDD) is challenging to treat. This study aimed to establish the prevalence of insomnia in youth with BDD and explore its impact on clinical outcomes. Sixty-six children and adolescents with BDD consecutively referred to a specialist clinic completed a range of clinical measures, including the Yale-Brown Obsessive-Compulsive Scale Modified for BDD-Adolescent Version (BDD-YBOCS-A), and the Insomnia Severity Index (ISI). Patients with clinical insomnia (ISI score ≥ 9) were compared to the rest of the sample on socio-demographic and clinical features. Fifty-six patients who received multimodal treatment were re-assessed post-treatment. A mixed-model ANOVA was performed to compare treatment outcomes between the insomnia vs. no insomnia groups, and Chi-squared tests were used to compare response and remission rates. According to the ISI, 48% of the sample qualified as having insomnia at baseline. These participants showed significantly higher self-reported BDD symptom severity, more depressive symptoms, and more functional impairment in daily activities. Patients with insomnia improved less on the BDD-YBOCS-A than those without insomnia, although the difference did not reach statistical significance. The rates of responders and remitters were lower in the insomnia group, compared to the non-insomnia group. Insomnia is prevalent in pediatric BDD, and is associated with more severe psychopathology and worse functioning in daily activities. Furthermore, youth experiencing BDD and insomnia may benefit from multimodal treatment to a lesser extent than those without insomnia. If these results are replicated in larger samples, treatment refinements for pediatric BDD could include specific modules to directly target insomnia.

Insomnia in pediatric obsessive-compulsive disorder: prevalence and association with multimodal treatment outcomes in a naturalistic clinical setting

OBJECTIVE

Little is known about the prevalence and impact of insomnia on clinical outcomes in youth with obsessive-compulsive disorder (OCD). This study aimed to investigate this subject.

PATIENTS/METHODS

A total of 193 patients from a specialist pediatric OCD clinic completed a range of diagnostic and clinical measures, including the Insomnia Severity Index (ISI). Patients scoring above a previously validated cut-off on the ISI (score ≥9) were compared to the rest of the sample on sociodemographic and clinical characteristics. In a subsample of 143 (from the initial 193) patients who were treated at the clinic, a mixed-model analysis of variance (ANOVA) was used to compare the outcomes of multimodal OCD treatment in the insomnia (N = 60) vs no insomnia (N = 83) groups. The primary outcome measure was the clinician-administered Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) at post-treatment and at three-month follow-up.

RESULTS

The psychometric properties of the ISI in our sample were excellent. At baseline, 42% (81/193) of the sample scored above the ISI cut-off for clinical insomnia. These participants had significantly higher OCD severity, higher rates of psychiatric comorbidities, more severe depressive symptoms, poorer general functioning, and were more likely to take sleep medications, compared to those who scored below the ISI cut-off. In the treated subsample, while the insomnia group remained more severely affected through the three time-points, both groups improved similarly on the CY-BOCS at post-treatment and at three-month follow-up.

CONCLUSION

Insomnia is relatively common in pediatric OCD and is associated with more severe psychopathology. However, with adequate multimodal, evidence-based treatment, these patients can improve as much as those without insomnia.

Therapist-Guided, Internet-Delivered Cognitive-Behavioral Therapy for Adolescents With Obsessive-Compulsive Disorder: A Randomized Controlled Trial

OBJECTIVE

Cognitive-behavioral therapy (CBT) is the first-line treatment for young people with obsessive-compulsive disorder (OCD), but most patients do not have access to this treatment. Thus, innovative ways to increase the accessibility of CBT are needed. The objective of this trial was to evaluate the efficacy of therapist-guided internet-based CBT (ICBT) for adolescents with OCD.

METHOD

Sixty-seven adolescents (12-17 years old) with OCD were randomly assigned to a 12-week clinician- and parent-supported ICBT program (BiP OCD) or a waitlist condition. The primary outcome was the Children Yale-Brown Obsessive Compulsive Scale (CY-BOCS) administered by blinded assessors before and after the intervention. All patients were followed up 3 months after the intervention.

RESULTS

In intention-to-treat analyses, BiP OCD was superior to waitlist on the CY-BOCS (time-by-group interaction, B = -4.53, z = -3.74, p < .001; Cohen's d = 0.69; 95% CI 0.19-1.18) and on most secondary outcome measurements. Patients randomized to BiP OCD also showed further improvement from post-treatment to 3-month follow-up, with a within-group pretreatment to follow-up effect size (Cohen's d) equal to 1.68 (95% CI 1.00-2.36). Patient satisfaction with BiP OCD was high. There were no relevant adverse events. Average clinician support time was 17.5 minutes per patient per week.

CONCLUSION

Therapist-guided ICBT is a promising low-intensity intervention for adolescents with OCD and has the potential to increase access to CBT. It might be particularly useful in a stepped-care approach, in which a large proportion of patients with moderately severe OCD could first be offered ICBT, thus freeing limited resources for more complex cases. Clinical trial registration information-Internet-Delivered CBT for Adolescents With OCD: A Randomized Controlled Study (BiPOCD); http://clinicaltrials.gov; NCT02191631.