Probabilistic reasoning in patients with body dysmorphic disorder

Background and Objectives

Many patients with body dysmorphic disorder (BDD) have poor insight into their condition. Indeed, their conviction in their ugliness is often delusional. Perhaps the most robust information-processing abnormality associated with delusions is a jumping to conclusions (JTC) reasoning bias such that delusional individuals request significantly less information before making a decision relative to healthy controls. We investigated whether patients with BDD (n = 20) demonstrate a JTC reasoning style relative to patients with OCD (n = 20) and healthy controls (n = 20).

Methods

Participants completed a clinician-rated measure of delusionality and two tests of probabilistic reasoning: the beads task and the survey task.

Results

Patients with BDD did exhibit higher delusionality than the patients with OCD. They did not, however, exhibit a JTC reasoning bias relative to the patients with OCD or the healthy controls. Patients with poor insight BDD requested significantly less information before making a decision than did patients with fair insight BDD.

Limitations

The clinical groups were characterized by multiple comorbidities and concomitant medications. The BDD group had relatively good insight as compared to other studies examining delusionality in BDD.

Conclusions

Taken together, our results suggest that although a JTC reasoning bias was not present in all patients with BDD, a modest JTC reasoning bias may be present among patients with poor insight BDD. Future studies could provide additional information on this hypothesis.     

Psychosocial functioning and quality of life in body dysmorphic disorder

Psychosocial functioning and quality of life in body dysmorphic disorder (BDD) have received only limited investigation. We examined these domains in 176 subjects with current Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), BDD using reliable measures, several of which have not been used previously in BDD studies. Scores were compared to published norms. On the Medical Outcomes Study 36-Item Short-Form Health Survey, mental health-related quality of life scores for BDD subjects were approximately 1.8 SD units poorer than US population norms and 0.4 SD units poorer than norms for depression. On the Quality of Life Enjoyment and Satisfaction Questionnaire Short Form, BDD subjects had a mean converted score of 49.9% +/- 16.4%, which was 2.1 SD units poorer than the normative community sample score of 78.1% +/- 13.7%. On the Social Adjustment Scale-Self-Report, BDD subjects had a mean Overall Adjustment total score of 2.37 +/- 0.52, which was 2.4 SD units poorer than the published norm of 1.59 +/- 0.33. Scores on the Range of Impaired Functioning Tool reflected functional impairment in all domains. More severe BDD symptoms were significantly associated with poorer functioning and quality of life on all measures. On all but one measure, functioning and quality of life for subjects who were not currently receiving mental health treatment did not significantly differ from those who were receiving treatment. These findings indicate that individuals with BDD, regardless of treatment status, have markedly poor functioning and quality of life. In addition, they suggest that treatment should aim at improving functioning and quality of life in addition to relieving symptoms.     

Personality disorders and traits in patients with body dysmorphic disorder

Individuals with body dysmorphic disorder (BDD) have been postulated to have schizoid, narcissistic, and obsessional personality traits and to be sensitive, introverted, perfectionistic, and insecure. However, data on personality traits and disorders in BDD are limited. This study assessed 148 subjects with BDD, 26 of whom participated in a fluvoxamine treatment study; 74 subjects were assessed for personality disorders with the Structured Clinical Interview for DSMIII-R Personality Disorders (SCID-II), 100 subjects completed the NEO-Five Factor Inventory (NEO-FFI), and 51 subjects completed the Rathus Assertiveness Scale. Forty-two subjects (57%) had one or more personality disorders, with avoidant personality disorder (43%) being most common, followed by dependent (15%), obsessive-compulsive (14%), and paranoid (14%) personality disorders. On the NEO-FFI, the mean scores were in the very high range for neuroticism, the low range for extraversion and conscientiousness, the low-average range for agreeableness, and the average range for openness to experience. On the Rathus Assertiveness Scale, the mean score was -17.1 +/- 32.0 for women and -17.0 +/- 32.3 for men. Among fluvoxamine responders, the number of personality disorders significantly decreased between the study baseline and endpoint. These findings suggest that the rate of personality disorders in BDD is relatively high, with avoidant personality disorder being most common. The high neuroticism scores and low extraversion scores are consistent with this finding.     

Psychosis in body dysmorphic disorder

Body dysmorphic disorder (BDD) has both psychotic and nonpsychotic variants, which are classified as separate disorders in DSM-IV (delusional disorder and a somatoform disorder). Despite their separate classification, available evidence indicates that BDD's delusional and nondelusional forms have many similarities (although the delusional variant appears more severe), suggesting that they may actually be the same disorder, characterized by a spectrum of insight. And contrary to what might be expected, BDD's delusional form, although classified as a psychotic disorder, appears to respond to serotonin-reuptake inhibitors alone. These and other data suggest that a dimensional view of psychosis (in particular, delusions) in these disorders may be more accurate than DSM's current categorical view. A dimensional model might also facilitate more consistent and accurate classification of other disorders that are likely characterized by a spectrum of insight, such as obsessive compulsive disorder, hypochondriasis, and anorexia nervosa. Further research is needed to better understand these classification issues, which likely have treatment implications.     

SPECT imaging of body dysmorphic disorder

[99mTc]Hexamethylpropylene amine oxime (HMPAO) single photon emission computed tomography (SPECT) brain scans were undertaken in six subjects with body dysmorphic disorder (BDD). The scans showed a broad range of discrepant findings that do not immediately support a view of BDD as resting on either an obsessive-compulsive or affective disorder spectrum. Nevertheless, involvement of parietal regions is consistent with the characteristic altered body perception of BDD. These preliminary data highlight the need for further systematic functional imaging studies of this condition.     

Traumatic experiences in individuals with body dysmorphic disorder

Individuals with body dysmorphic disorder (BDD) are excessively concerned about perceived defects in their appearance (e.g., blemishes on their skin). BDD is a severe mental disorder often associated with increased suicidality as well as significant social and occupational interference (e.g., J Clin Psychiatry 2005;66:717-725). Recently, investigators have begun to explore variables that might function as risk factors in the development of BDD, such as traumatic experiences (e.g., Child Abuse Negl 2006;30:1105-1115). As such, one of the goals of the current study was to examine the role of early-life sexual, physical, or emotional abuse in BDD. Specifically, the Traumatic Stress Institute Life Event Questionnaire (Treat Abuse Today 1992;2:9-11) was used to examine whether individuals with BDD (n = 18) self-reported having experienced more traumatic events than mentally healthy controls (n = 19). The BDD group reported more retrospective experiences of sexual and physical abuse in childhood or adolescence than did healthy controls. Surprisingly, there was no significant group difference in reports of emotional abuse in early life. This study provides preliminary evidence of the importance of examining abuse as a potential risk factor in the development of BDD.     

An update on body dysmorphic disorder

PURPOSE OF REVIEW: The present review provides an update on current research into body dysmorphic disorder. RECENT FINDINGS: Recent findings can be considered under four groupings: the classification of body dysmorphic disorder, its current inclusion under the somatoform disorders, and its relationship to obsessive compulsive disorder and other obsessive compulsive spectrum disorders; the psychotic 'variant' of body dysmorphic disorder, and whether it is simply a more severe form of the nonpsychotic type; the cognitive aspects of body dysmorphic disorder; and the treatment of body dysmorphic disorder, both in terms of pharmacological and psychological parameters. SUMMARY: Body dysmorphic disorder does not sit comfortably in the somatoform disorder category, and there is a good case for it being considered part of the obsessive compulsive spectrum, although it is not merely a subtype of obsessive compulsive disorder. Insight into the illness suggests that it represents a spectrum of disorders, and a categorical delineation of 'psychotic' and 'nonpsychotic' variants cannot be supported. We are beginning to understand more about the neurocognitive aspects of body dysmorphic disorder, but more research is required to assess which deficits/aberrations (if any) are exclusive to body dysmorphic disorder as an entity, and which are a reflection of broader phenomenological manifestations. Finally, the mainstay of treatment for body dysmorphic disorder remains behaviour/cognitive behaviour therapy and serotonin reuptake inhibitors; much more work is required to identify effective interventions for those patients who fail to respond to these treatment modalities.     

Dysmorphophobia (body dysmorphic disorder)]

This article reviews the historical and terminological origins of dysmorphophobia from Herodotus to today. It explains the differences pointed out by many authors, including the DSM-III-R, between body dismorphic disorder and delusional disorder somatic type, which are referred to as monosymptomatic hypochondriacal psychoses in Europe. Epidemiological data, clinical characteristics and outcome are discussed. Explicative theories and neurobiological, developmental and analytical aspects of body image are presented. The association between body dismorphic disorder and other disorders is analyzed, and treatment possibilities are discussed. The authors suggest that body dismorphic disorder be classified with obsessive compulsive disorder, whatever the intensity of symptomatology, rather than with somatoform or delusional disorder, and treated with serotonin uptake inhibitors or neureptics that have been proven to be effective for the treatment of this disorder, such as pimozide.     

Clinical and subclinical body dysmorphic disorder

Background The aim of the study was to define the main demographic and clinical characteristics of Body Dysmorphic Disorder (BDD) and subclinical BDD (sBDD) in a sample derived by a screening survey done on a population of individuals referring to aesthetical medicine centers. Method 487 subjects referring to hospital centers for aesthetical medicine were administered the SCID-I and the Yale-Brown Obsessive-Compulsive Scale adapted for BDD (BDD-YBOCS). The sample was thus sub-divided in three sub-samples: 1) BDD, 2) sub-clinical BDD, and 3) controls. The main demographic and clinical variables were considered and compared between the BDD and the sBDD samples. Results As previously reported, the prevalence of BDD and sBDD was 6.3 % and 18.4 %, respectively. The most frequent comorbid diagnosis in both BDD and sBDD patients and their relatives was Obsessive-Compulsive Disorder (OCD). A higher severity of symptoms was found in male BDD patients, while no gender-related differences were found in the sBDD group. Suicidal ideation was found in 12.1 % of the sBDD and in 49.7 % of the BDD patients. Conclusions These results support the hypothesis of BDD and sBDD belonging to the OCD spectrum, and appear to advise long-term follow-up studies on the course and the prognosis of sBDD. Received: 5. December 2000 / Accepted: 21. March 2001     

Delusional versus nondelusional body dysmorphic disorder

This study assessed demographic and clinical features in 65 subjects with body dysmorphic disorder (BDD) and compared the 39 (60%) with the delusional form (receiving an additional diagnosis of delusional disorder, somatic type) with those who did not meet delusionality criteria. Delusional and nondelusional patients did not statistically differ on most demographic and clinical variables. Delusional patients, however, had significantly more severe BDD symptoms at both baseline and follow-up assessments than those of nondelusional patients. Furthermore, poorer insight was significantly associated with more severe BDD symptoms at both baseline and follow-up. Overall improvement in BDD symptom severity was similar for the 2 groups. Our results support other studies in the view that BDD and its delusional variant have more similarities than differences and that the delusional variant may be simply a more severe form of BDD. Implications for the diagnostic classification of BDD and future research directions are discussed.     

Status of body dysmorphic disorder in Argentina

Although body dysmorphic disorder (BDD) has received recent attention, it remains misunderstood and under-studied. The Argentine population seeks out plastic surgery at a disproportionate rate and exhibits high rates of preoccupation with bodily dissatisfaction, yet BDD is unrecognized and research is limited. The current study describes the prevalence, quality of life, and presentation style of BDD in depressed adolescents, as depression is the most common symptom for which adolescents seek treatment in Argentina. Twenty-five depressed adolescents and 85 non-depressed students were initially assessed for depression and BDD and subdivided depending on BDD status. Participants were assessed on various constructs including obsessions and compulsions, overvalued ideas, and overall level of impairment. A 2 × 2 factorial design was employed, and multivariate analysis of variance (MANOVA) was used to analyze the data. Significant main effects were observed for all dependent measures (BDI, OVIS, YBOCS, and Sheehan Disability Scale) for depressed vs. non-depressed participants and BDD status; significant interactions were observed between independent variables for all dependent measures. Depressed adolescents had significantly higher scores on the YBOCS-BDD, OVIS, BDI, and the Sheehan Disability Scale compared to non-depressed participants; furthermore, individuals reporting BDD symptoms reported significantly higher scores on the YBOCS-BDD, OVIS, BDI, and Sheehan Disability Scale. Significant interactions are discussed according to BDD status and depression on dependent measures. Patients with BDD have poor quality of life and present with anxiety and depression, yet it still remains underdiagnosed.     

Substance use disorders in individuals with body dysmorphic disorder

BACKGROUND: Little is known about substance use disorders (SUDs) in individuals with body dysmorphic disorder (BDD). Although studies have examined SUD comorbidity in BDD, no previous studies have examined clinical correlates of SUD comorbidity. METHOD: We examined rates and clinical correlates of comorbid SUDs in 176 consecutive subjects with DSM-IV BDD (71% female; mean +/- SD age = 32.5 +/- 12.3 years). Comorbidity data were obtained with the Structured Clinical Interview for DSM-IV. BDD severity was assessed with the Yale-Brown Obsessive Compulsive Scale Modified for BDD, and delusionality (insight) was assessed with the Brown Assessment of Beliefs Scale. Quality of life and social/occupational functioning were examined using the Social Adjustment Scale, Quality of Life Enjoyment and Satisfaction Questionnaire, Medical Outcomes Study 36-Item Short-Form Health Survey, and Range of Impaired Functioning Tool. All variables were compared in BDD subjects with and without lifetime and current SUDs. Data were collected from January 2001 to June 2003. RESULTS: 48.9% of BDD subjects (N = 86) had a lifetime SUD, 29.5% had lifetime substance abuse, and 35.8% had lifetime substance dependence (most commonly, alcohol dependence [29.0%]). 17% (N = 30) had current substance abuse or dependence (9.1% reported current substance abuse, and 9.7% reported current dependence). 68% of subjects with a lifetime SUD reported that BDD contributed to their SUD. There were far more similarities than differences between subjects with a comorbid SUD and those without an SUD, although those with a lifetime SUD had a significantly higher rate of suicide attempts (p = .004). CONCLUSION: These preliminary results suggest that SUDs are very common in individuals with BDD. Subjects with and without a comorbid SUD were similar in most domains that were examined.     

躯体变形障碍合并边缘型人格障碍的访谈与治疗

咨客,女性,25岁,经常感觉眼睛变小,反复为此纠结。个人情绪不稳定、易激动,在人际关系方面存在问题。在本次咨询中患者被诊断为躯体变形障碍合并边缘型人格障碍,建议采用生物-心理-社会的综合干预模式治疗。鼓励咨客规律运动,服用选择性5-羟色胺再摄取抑制剂(SSRIs)和第二代抗精神病药物联合治疗;采用辩证行为治疗(DBT)调整咨客认知、稳定情绪、改善人际技能;工作上建议选择人际压力小的工作环境,如影像学类临床辅助科室。     

Pathological skin picking in individuals with body dysmorphic disorder

OBJECTIVE: The objective of this study was to examine the prevalence and clinical correlates of pathological skin picking (PSP) in a large sample of individuals with body dysmorphic disorder (BDD). METHOD: One hundred seventy-six individuals with BDD (71.0% women; mean age, 32.5+/-12.3 years) were assessed with respect to comorbidity, BDD severity, delusionality (insight), quality of life and social/occupational functioning, using reliable and valid measures. All variables were compared in BDD subjects with and without lifetime PSP. RESULTS: About 44.9% of subjects reported lifetime PSP, and 36.9% reported current PSP secondary to BDD. BDD subjects with PSP were more likely to be female, to have skin preoccupations, to have comorbid trichotillomania or a personality disorder, to camouflage with makeup and to seek and receive nonpsychiatric (e.g., dermatological) treatment for their skin preoccupations. CONCLUSION: There is a high prevalence of PSP among individuals with BDD, and clinicians should be aware of the clinical correlates of this problematic behavior.     

Insight in obsessive compulsive disorder and body dysmorphic disorder

Similarities between obsessive-compulsive disorder (OCD) and body dysmorphic disorder (BDD) have been described in terms of clinical presentation, comorbidity rates, treatment response profiles, and other features. This is the first study to compare insight in OCD and BDD measuring global insight and numerous components of insight. We compared insight in 64 adult outpatients with DSM-IV OCD and 85 adult outpatients with DSM-IV BDD using a reliable and valid measure (the Brown Assessment of Beliefs Scale [BABS]). BDD patients had significantly poorer global insight than OCD patients. BDD patients also had significantly poorer insight on the following components of insight: conviction that the belief is accurate, perception of other's views of the belief, explanation for differing views, willingness to consider that the belief is wrong, and recognition that the belief has a psychiatric/psychological cause. Poorer insight was significantly positively correlated with more severe symptoms of the disorder only in the BDD group.