Abstract
Individuals with body dysmorphic disorder (BDD) experience elevated social avoidance, both as a consequence and independent of BDD concerns. To explore how social avoidance relates to the long-term course of functioning for people with BDD, this prospective longitudinal study evaluated the hypothesis that initial social avoidance would predict changes in psychosocial functioning over 3 years, such that greater initial social avoidance would predict worsening functioning. At intake, individuals with BDD (N = 200) completed measures of social avoidance independent of BDD, social avoidance due to BDD or any other source, overall psychosocial functioning, and psychosocial functioning in specific domains. Overall and specific functioning was prospectively evaluated at three subsequent yearly follow-up assessments. Mixed model analyses evaluated the relation between baseline social avoidance and changes in functioning. Results provided mixed support for hypotheses, indicating that higher baseline social avoidance independent of BDD predicted worsening functioning in two of the four overall functioning indices and in both specific domains—interpersonal relationship quality and work/academic/household functioning. Higher global social avoidance (due to BDD or any other source) predicted poorer overall functioning for two of the four global functioning indices but did not predict functioning in either specific domain. Social avoidance, both related and unrelated to body image, might play an important role in the trajectory of psychosocial functioning for people with BDD.
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Notes
DSM-IV-TR criteria for BDD did not include the repetitive behavior criterion that was added in DSM-5. However, when responding to items on the baseline survey, all participants reporting engaging in at least two different repetitive behaviors (e.g., checking one’s appearance in mirror, comparing one’s appearance to the appearance of others, seeking reassurance) over the course of their lifetime (average number of repetitive behaviors = 6.93), suggesting the entire sample would have met DSM-5 criteria for BDD. Likewise, when responding to items on the BDD-YBOCS at baseline, 96% of the total sample reported engaging in past week repetitive behavior.
References
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: American Psychiatric Association.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: American Psychiatric Association.
Antony, M. M., Coons, M. J., McCabe, R. E., Ashbaugh, A., & Swinson, R. P. (2006). Psychometric properties of the social phobia inventory: Further evaluation. Behaviour Research and Therapy,44, 1177–1185. https://doi.org/10.1016/j.brat.2005.08.013.
Buhlmann, U., McNally, R. J., Wilhelm, S., & Florin, I. (2002). Selective processing of emotional information in body dysmorphic disorder. Journal of Anxiety Disorders,16, 289–298. https://doi.org/10.1093/med/9780190254131.003.0022.
Chawla, N., & Ostafin, B. (2007). Experiential avoidance as a functional dimensional approach to psychopathology: An empirical review. Journal of Clinical Psychology,63, 871–890. https://doi.org/10.1002/jclp.20400.
Connor, K. M., Davidson, J. R., Churchill, L. E., Sherwood, A., Weisler, R. H., & Foa, E. (2000). Psychometric properties of the Social Phobia Inventory (SPIN): New self-rating scale. The British Journal of Psychiatry,176, 379–386. https://doi.org/10.1192/bjp.176.4.379.
Davidson, J. R., Miner, C. M., De Veaugh-Geiss, J., Tupler, L. A., Colket, J. T., & Potts, N. L. S. (1997). The brief social phobia scale: A psychometric evaluation. Psychological Medicine,27, 161–166. https://doi.org/10.1017/s0033291796004217.
Didie, E. R., Menard, W., Stern, A. P., & Phillips, K. A. (2008). Occupational functioning and impairment in adults with body dysmorphic disorder. Comprehensive Psychiatry,49, 561–569. https://doi.org/10.1016/j.comppsych.2008.04.003.
Diggle, P., Liang, K., & Zeger, S. L. (1994). Analysis of longitudinal data. Oxford: Clarendon Press.
First, M. B., Spitzer, R. L., Gibbon, M., & Williams, J. B. W. (1996). Structured clinical interview for DSM-IV axis I disorders, non-patient edition (SCID-NP, version 2.0). New York: Biometrics Research Dept.
Hayes, S. C., & Hofmann, S. G. (2018). Process-based CBT: The science and core clinical competencies of cognitive behavioral therapy. Oakland, CA: New Harbinger Publications.
Hendriks, S. M., Spijker, J., Licht, C. M., Hardeveld, F., de Graaf, R., Batelaan, N. M., et al. (2016). Long-term disability in anxiety disorders. BMC Psychiatry,16, 248–256. https://doi.org/10.1186/s12888-016-0946-y.
Kashdan, T. B., Barrios, V., Forsyth, J. P., & Steger, M. F. (2006). Experiential avoidance as a generalized psychological vulnerability: Comparisons with coping and emotion regulation strategies. Behaviour Research and Therapy,44, 1301–1320. https://doi.org/10.1016/j.brat.2005.10.003.
Kashdan, T. B., & Kane, J. Q. (2011). Post-traumatic distress and the presence of post-traumatic growth and meaning in life: Experiential avoidance as a moderator. Personality and Individual Differences,50, 84–89. https://doi.org/10.1016/j.paid.2010.08.028.
Kashdan, T. B., Morina, N., & Priebe, S. (2009). Post-traumatic stress disorder, social anxiety disorder, and depression in survivors of the Kosovo War: Experiential avoidance as a contributor to distress and quality of life. Journal of Anxiety Disorders,23, 185–196. https://doi.org/10.1016/j.janxdis.2008.06.006.
Keller, M. B., Lavori, P. W., Friedman, B., Nielsen, E., Endicott, J., McDonald-Scott, P., et al. (1987). The Longitudinal Interval Follow-up Evaluation: A comprehensive method for assessing outcome in prospective longitudinal studies. Archives of General Psychiatry,44, 540–548. https://doi.org/10.1001/archpsyc.1987.01800180050009.
Kelly, M. M., Brault, M. E., & Didie, E. R. (2017). Psychosocial functioning and quality of life in body dysmorphic disorder. In K. A. Phillips (Ed.), Body dysmorphic disorder: Advances in research and clinical practice (pp. 139–154). New York: Oxford University Press. https://doi.org/10.1093/med/9780190254131.003.0012
Kelly, M. M., Walters, C., & Phillips, K. A. (2010). Social anxiety and its relationship to functional impairment in body dysmorphic disorder. Behavior Therapy,41, 143–153. https://doi.org/10.1016/j.beth.2009.01.005.
Levin, M. E., MacLane, C., Daflos, S., Seeley, J. R., Hayes, S. C., Biglan, A., et al. (2014). Examining psychological inflexibility as a transdiagnostic process across psychological disorders. Journal of Contextual Behavioral Science,3, 155–163. https://doi.org/10.1016/j.jcbs.2014.06.003.
Marques, L., Weingarden, H. M., LeBlanc, N. J., & Wilhelm, S. (2011). Treatment utilization and barriers to treatment engagement among people with body dysmorphic symptoms. Journal of Psychosomatic Research,70, 286–293. https://doi.org/10.1016/j.jpsychores.2010.10.002.
Phillips, K. A., & Diaz, S. F. (1997). Gender differences in body dysmorphic disorder. The Journal of Nervous and Mental Disease,185, 570–577. https://doi.org/10.1097/00005053-199709000-00006.
Phillips, K. A., Hollander, E., Rasmussen, S. A., & Aronowitz, B. R. (1997). A severity rating scale for body dysmorphic disorder: Development, reliability, and validity of a modified version of the Yale-Brown Obsessive Compulsive Scale. Psychopharmacology Bulletin,33, 17–22.
Phillips, K. A., Hart, A. S., & Menard, W. (2014). Psychometric evaluation of the Yale-Brown Obsessive-Compulsive Scale modified for body dysmorphic disorder (BDD-YBOCS). Journal of Obsessive-Compulsive and Related Disorders,3, 205–208. https://doi.org/10.1016/j.jocrd.2014.04.004.
Phillips, K. A., Menard, W., Fay, C., & Pagano, M. E. (2005a). Psychosocial functioning and quality of life in body dysmorphic disorder. Comprehensive Psychiatry,46, 254–260. https://doi.org/10.1016/j.comppsych.2004.10.004.
Phillips, K. A., Menard, W., Fay, C., & Weisberg, R. (2005b). Demographic characteristics, phenomenology, comorbidity, and family history in 200 individuals with body dysmorphic disorder. Psychosomatics,46, 317–325. https://doi.org/10.1176/appi.psy.46.4.317.
Phillips, K. A. (2017). Pharmacotherapy and other somatic treatments for body dysmorphic disorder. In K. A. Phillips (Ed.), Body dysmorphic disorder: Advances in research and clinical practice (pp. 333–356). New York: Oxford University Press. https://doi.org/10.1093/med/9780190254131.003.0025
Phillips, K. A. (2015). Body dysmorphic disorder. In K. A. Phillips & D. J. Stein (Eds.), Handbook on obsessive-compulsive and related disorders (pp. 57–98). Arlington, VA: American Psychiatric Publishing Inc.
Phillips, K. A., Quinn, G., & Stout, R. L. (2008). Functional impairment in body dysmorphic disorder: A prospective, follow-up study. Journal of Psychiatric Research,42, 701–707. https://doi.org/10.1016/j.jpsychires.2007.07.010.
Pinto, A., & Phillips, K. A. (2005). Social anxiety in body dysmorphic disorder. Body Image,2, 401–405. https://doi.org/10.1016/j.bodyim.2005.10.003.
Rasmussen, J., Gomez, A. F., & Wilhelm, S. (2017). Cognitive-behavioral therapy for body dysmorphic disorder. In K. A. Phillips (Ed.), Body dysmorphic disorder: Advances in research and clinical practice (pp. 357–378). New York: Oxford University Press. https://doi.org/10.1093/med/9780190254131.003.0026
Singer, J. D., & Willett, J. B. (2003). Applied longitudinal data analysis: Modeling change and event occurrence. New York: Oxford University Press.
Suárez, L. M., Bennett, S. M., Goldstein, C. R., & Barlow, D. H. (2009). Understanding anxiety disorders from a "triple vulnerability" framework. In M. M. Antony & M. B. Stein (Eds.), Oxford library of psychology. Oxford handbook of anxiety and related disorders (pp. 153–172). New York: Oxford University Press. https://doi.org/10.1093/oxfordhb/9780195307030.013.0013
Tasca, G. A., & Gallop, R. (2009). Multilevel modeling of longitudinal data for psychotherapy researchers: I. The basics. Psychotherapy Research,19, 429–437. https://doi.org/10.1080/10503300802641444.
Warshaw, M. G., Keller, M. B., & Stout, R. L. (1994). Reliability and validity of the longitudinal interval follow-up evaluation for assessing outcome of anxiety disorders. Journal of Psychiatric Research,28, 531–545. https://doi.org/10.1016/0022-3956(94)90043-4.
Weingarden, H., Shaw, A. M., Phillips, K. A., & Wilhelm, S. (2018). Shame and defectiveness beliefs in treatment-seeking patients with body dysmorphic disorder. Journal of Nervous and Mental Disease,206, 417–422. https://doi.org/10.1097/nmd.0000000000000808.
Wilhelm, S., Phillips, K. A., Greenberg, J. L., O’Keefe, S. M., Hoeppner, S. S., Keshaviah, A., et al. (2019). Efficacy and posttreatment effects of therapist-delivered cognitive behavioral therapy vs supportive psychotherapy for adults with body dysmorphic disorder. JAMA Psychiatry,76, 363. https://doi.org/10.1001/jamapsychiatry.2018.4156.
Wilhelm, S., Phillips, K. A., & Steketee, G. (2013). Cognitive-behavioral therapy for body dysmorphic disorder: A treatment manual. New York: Guilford Press.
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This study was supported by the National Institutes of Mental Health (R01 MH6024).
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The first four authors declare no conflicts of interest. The last author receives royalties for sale of scholarly books and writing published by Oxford University Press, Wolter’s Kluwer, and Guilford Press, received a Merck Manual writing honorarium, and has received several speaking honoraria and travel reimbursement from a variety of professional organizations and academic institutions.
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Ritzert, T.R., Brodt, M., Kelly, M.M. et al. Social Avoidance as a Predictor of Psychosocial Functioning in Body Dysmorphic Disorder: A Prospective Longitudinal Analysis. Cogn Ther Res 44, 557–566 (2020). https://doi.org/10.1007/s10608-019-10069-0
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DOI: https://doi.org/10.1007/s10608-019-10069-0