Etiology, prevalence, and development of a novel treatment for body dysmorphic disorder

Body dysmorphic disorder (BDD) is characterized by an intense preoccupation with perceived defects in physical appearance that are not noticeable, or only appear slight to others. While effective treatment for this disorder does exist (e.g. cognitive behavioural therapy; CBT) most sufferers do not get access to it. BDD usually begins during adolescence but few studies have explored the prevalence and pattern of comorbidities in this age group. Moreover, the etiology of dysmorphic concerns in young people is unknown. The aims of this thesis were therefore to develop a novel therapist-guided internet-based CBT program for BDD (BDD-NET), with the intention to increase availability of CBT for BDD, and to conduct a genetic epidemiological study of BDD symptoms in adolescents and young adults. In Study I, the feasibility of BDD-NET was evaluated in a sample of 23 self-referred adults diagnosed with BDD. Large and significant reductions in BDD symptoms were observed after treatment, and participants deemed the treatment as highly acceptable. In Study II, the efficacy of BDD-NET was determined in a single-blind randomized controlled trial. Ninety-four participants with BDD were randomized to BDD-NET or online supportive therapy. BDD-NET was superior to supportive therapy, and 39% of those that had received BDD-NET were in remission, compared to 9% in the control group. All participants in the control group were offered BDD-NET after the controlled follow-up. In Study III, all participants (n=88) that had received BDD-NET in Study II were followed-up for 2-years to evaluate the long-term efficacy of BDD-NET. The treatment effects of BDDNET were sustained in the long-term and at the 2-year follow-up, 56% of participants were in remission. In Study IV, the prevalence of clinically significant BDD symptoms, and risks for co-existing psychopathology were estimated in three population-based twin cohorts at ages 15 (n=6,968), 18 (n=3,738), and 20-28 (n=4,671). A classical twin design was used to determine the relative contribution of genetic and environmental influences on body dysmorphic concerns in these age groups. The prevalence of BDD was estimated between 1% and 2%. Heritability of dysmorphic concerns was estimated between 37-49%, with the remaining variance explained by non-shared environment. The risks for co-existing psychopathology were elevated, with odds ratios ranging from 2.3-13.2. In conclusion, BDD-NET is an efficacious treatment for this disorder, both in the short-term and in the long-term, and it has the potential to increase access to evidence based care for people with BDD. BDD symptoms in young people are relatively common, with genetic factors accounting for roughly half of the variation in dysmorphic concerns. The risks for coexisting psychopathology are elevated in young people that screened positive for BDD

BDD-NET – Ein internetbasiertes Programm bei Körperunzufriedenheit zur niedrigschwelligen Behandlung der körperdysmorphen Störung für den deutschen Sprachraum

Hintergrund: Die Körperdysmorphe Störung (KDS) ist eine schwerwiegende psychische Störung, die mit starker Scham sowie Leidensdruck und Funktionseinschränkungen einhergeht. Kognitive Verhaltenstherapie stellt die aktuell wirksamste evidenzbasierte Behandlungsmethode dar. Aufgrund zahlreicher Behandlungsbarrieren kommen KDS-Betroffene jedoch selten in der psychotherapeutischen Behandlung an, weshalb niedrigschwelligen Behandlungsmethoden (z.B. aus dem Bereich E-Mental-Health) eine wichtige Rolle zukommen könnten. Erste internationale Studien weisen auf die Wirksamkeit von E-Mental-Health-Angeboten bei KDS hin. Material und Methoden: Dieser Beitrag gibt eine Übersicht zur bisherigen Umsetzung und Evidenz von E-Mental-Health-Angeboten für KDS und stellt die ins Deutsche übersetzte Version des BDD-NET-Programms, eines internetbasierten, manuali­sierten, therapeutenbegleiteten Interventionsprogramms, für die KDS vor, welches aus dem Englischen für den deutschen Sprachraum übersetzt und adaptiert wurde. Ergebnisse: BDD-NET umfasst acht Module, die binnen einer 12-wöchigen Behandlung online bearbeitet werden. Die Online-Plattform bietet für die Patienten die Möglichkeit, mit dem BDD-NET-Therapeuten mittels persönlicher Nachrichten zu kommunizieren. Sämtliche Materialien wurden aus dem Englischen übersetzt und vor allem in kultureller Hinsicht adaptiert. Schlussfolgerungen: BDD-NET könnte ein wichtiger Baustein in der Versorgung von KDS-Betroffenen sein. Die Evaluation steht für den deutschen Sprachraum noch aus. Auf Besonderheiten des Settings (z.B. Störungseinsicht als möglicher Behandlungsfokus) sowie praktische Implikationen wird eingegangen. Zudem werden Voraussetzungen und Rahmenbedingungen für eine perspektivische Dissemination diskutiert

Adapted cognitive behavior therapy for obsessive compulsive disorder with co-occurring autism spectrum disorder: A clinical effectiveness study

Obsessive-compulsive disorder (OCD) and autism spectrum disorder (ASD) commonly co-occur. Adapted CBT for OCD in adults with ASD has not previously been evaluated outside the United Kingdom. In this study, 19 adults with OCD and ASD were treated using an adapted CBT protocol that consisted of 20 sessions focused on exposure with response prevention. The primary outcome was the clinician-rated Yale-Brown Obsessive-Compulsive Scale (YBOCS). Participants were assessed up to 3 months after treatment. There were significant reductions on the YBOCS at post-treatment (d=1.5), and improvements were sustained at follow-up (d=1.2). Self-rated OCD symptoms and depressive symptoms showed statistically significant reductions. Improvements in general functioning and quality of life were statistically non-significant. Three participants (16%) were responders at post-treatment and four (21%) were in remission from OCD. At follow-up, three participants (16%) were responders and one (5%) was in full remission. Adapted CBT for OCD in adults with co-occurring ASD is associated with reductions in obsessive-compulsive symptoms and depressive symptoms. However, outcomes are modest; few patients were completely symptom free, and treatment engagement was low with few completed exposures and low adherence to homework assignments. We identify and discuss the need for further treatment refinement for this vulnerable group

Cost-effectiveness of internet-delivered cognitive behaviour therapy for body dysmorphic disorder: Results from a randomised controlled trial

Objectives: To evaluate the cost-effectiveness of internet-delivered cognitive behaviour therapy for body dysmorphic disorder (BDD-NET). Design: Secondary cost-effectiveness analysis from a randomised controlled trial on BDD-NET versus online supportive psychotherapy. Setting: Academic medical center. Participants: Self-referred adult participants with a primary diagnosis of body dysmorphic disorder and a score of 20 or higher on the modified Yale-Brown Obsessive Compulsive Scale for BDD (n = 94). Patients receiving concurrent psychotropic drug treatment were included if the dose had been stable for at least two months. Interventions: Participants received either BDD-NET (n = 47) or online supportive psychotherapy (n = 47) for 12 weeks. Primary and secondary outcome measures: The primary outcome measures were cost-effectiveness and cost-utility from a societal perspective, using remission status from a diagnostic interview and quality-adjusted life years (QALY), respectively. Secondary outcome measures were cost-effectiveness and cost-utility from a health care perspective and the clinic's perspective. Results: Compared to supportive psychotherapy, BDD-NET produced one additional remission for an average societal cost of $4132. The cost-utility analysis showed that BDD-NET generated one QALY to an average cost of$14,319 from a societal perspective. Conclusions: BDD-NET is a cost-effective treatment for body dysmorphic disorder, compared to online supportive psychotherapy. The efficacy and cost-effectiveness of BDD-NET should next be directly compared to in-person cognitive behaviour therapy. Trial registration: NCT02010619

The developmental origins of hoarding disorder in adolescence: a longitudinal clinical interview study following an epidemiological survey

BACKGROUND: Hoarding disorder (HD) is hypothesized to originate in childhood/adolescence but little is known about the presentation of hoarding symptoms in youth and their natural history. In this longitudinal study, we tracked and conducted in-depth psychiatric interviews with twins who participated in an epidemiological survey and screened positive on a measure of hoarding symptoms at age 15. METHODS: Twins screening positive for clinically significant hoarding symptoms at age 15 (n=42), their co-twins (n= 33), a group of screen negative twins (n=49), and their parents underwent a clinical assessment a median of 3 years after the initial screening. The assessment included psychiatric screening, hoarding symptoms and cognitions, in-home or photographic assessment of clutter levels, parental accommodation and familial burden. RESULTS: None of the participants had significant levels of clutter at follow-up and thus did not meet strict criteria for HD. However, twins meeting partial criteria (i.e. DSM-5 criteria A and B) for HD (n=28) had more psychiatric disorders and scored significantly higher on all measures of hoarding symptoms including researcher-rated levels of clutter in their homes, compared to twins who did not meet criteria for HD (n=46). CONCLUSIONS: As currently defined in DSM-5, HD may be rare in young people. A non-negligible proportion of young people who were screen positive on hoarding symptoms at age 15 had substantial hoarding symptoms and other psychopathology at follow-up. Whether and how many of these individuals will develop full-blown HD is unknown but the results offer unique insights about the probable origins of HD

Adapted cognitive behavior therapy for obsessive compulsive disorder with co-occurring autism spectrum disorder: A clinical effectiveness study

Obsessive–compulsive disorder and autism spectrum disorder commonly co-occur. Adapted cognitive behavior therapy for obsessive–compulsive disorder in adults with autism spectrum disorder has not previously been evaluated outside the United Kingdom. In this study, 19 adults with obsessive–compulsive disorder and autism spectrum disorder were treated using an adapted cognitive behavior therapy protocol that consisted of 20 sessions focused on exposure with response prevention. The primary outcome was the clinician-rated Yale–Brown Obsessive–Compulsive Scale. Participants were assessed up to 3 months after treatment. There were significant reductions on the Yale–Brown Obsessive–Compulsive Scale at post-treatment (d = 1.5), and improvements were sustained at follow-up (d = 1.2). Self-rated obsessive–compulsive disorder and depressive symptoms showed statistically significant reductions. Improvements in general functioning and quality of life were statistically non-significant. Three participants (16%) were responders at post-treatment and four (21%) were in remission from obsessive–compulsive disorder. At follow-up, three participants (16%) were responders and one (5%) was in full remission. Adapted cognitive behavior therapy for obsessive–compulsive disorder in adults with co-occurring autism spectrum disorder is associated with reductions in obsessive–compulsive symptoms and depressive symptoms. However, outcomes are modest; few patients were completely symptom free, and treatment engagement was low with few completed exposures and low adherence to homework assignments. We identify and discuss the need for further treatment refinement for this vulnerable group.</p

Study on resting, roosting, foraging and nesting sites of few bird species at Mysore district, Karnataka, India

Three rhizosphere fungal isolates viz., PGPFYCM-2, PGPFYCM-8 and PGPFYCM-14 of Trichoderma harzianum, applied as seed treatment to a highly susceptible sunflower cultivar were evaluated for their ability to promote growth and induce resistance in sunflower against downy mildew disease caused by Plasmopara halstedii. Treatment of sunflower seeds with both conidial suspension (1þinspace×þinspace108 spores ml−1) and talc formulations (2.1þinspace×þinspace107 spores g−1) at 8 gþinspacekg−1 seeds and 10 gþinspacekg−1 seeds, significantly promoted growth and reduced disease incidence under both greenhouse and field conditions. Among the treatments, PGPFYCM-14 (1þinspace×þinspace108 spores ml−1) was highly significant (Pþinspace=þinspace0.05) in inducing resistance of 63 and 69 %, followed by PGPFYCM-2 which offered 41 and 42 % disease protection under greenhouse and field conditions respectively. Formulation treatments of PGPFYCM-14 also protected the plants significantly (Pþinspace=þinspace0.05) when compared to the untreated control. There was a significant increase in NPK macronutrients uptake in all the treated plants compared to the untreated control and maximum NPK uptake was observed with PGPFYCM-14 (1þinspace×þinspace108 spores ml−1). Under in vitro conditions, all the tested isolates expressed increase in seed germination and vigour index over the control. Tested plant growth promoting fungal (PGPF) isolates remain significant in enhancing vegetative and reproductive growth parameters, including plant height, early flowering, reduced crop duration, ear head size and crop yield under field conditions when compared to the untreated control

Therapist guided internet based cognitive behavioural therapy for body dysmorphic disorder: single blind randomised controlled trial

OBJECTIVES To evaluate the efficacy of therapist guided internet based cognitive behavioural therapy (CBT) programme for body dysmorphic disorder (BDD-NET) compared with online supportive therapy. DESIGN A 12 week single blind parallel group randomised controlled trial. SETTING Academic medical centre. PARTICIPANTS 94 self referred adult outpatients with a diagnosis of body dysmorphic disorder and a modified Yale-Brown obsessive compulsive scale (BDD-YBOCS) score of &amp;gt;= 20. Concurrent psychotropic drug treatment was permitted if the dose had been stable for at least two months before enrolment and remained unchanged during the trial. INTERVENTIONS Participants received either BDD-NET (n=47) or supportive therapy (n=47) delivered via the internet for 12 weeks. MAIN OUTCOME MEASURES The primary outcome was the BDD-YBOCS score after treatment and follow-up (three and six months from baseline) as evaluated by a masked assessor. Responder status was defined as a &amp;gt;= 30% reduction in symptoms on the scale. Secondary outcomes were measures of depression (MADRS-S), global functioning (GAF), clinical global improvement (CGI-I), and quality of life (EQ5D). The six month follow-up time and all outcomes other than BDD-YBOCS and MADRS-S at 3 months were not pre-specified in the registration at clinicaltrials.gov because of an administrative error but were included in the original trial protocol approved by the regional ethics committee before the start of the trial. RESULTS BDD-NET was superior to supportive therapy and was associated with significant improvements in severity of symptoms of body dysmorphic disorder (BDD-YBOCS group difference -7.1 points, 95% confidence interval -9.8 to -4.4), depression (MADRS-S group difference -4.5 points, -7.5 to -1.4), and other secondary measures. At follow-up, 56% of those receiving BDD-NET were classed as responders, compared with 13% receiving supportive therapy. The number needed to treat was 2.34 (1.71 to 4.35). Self reported satisfaction was high. CONCLUSIONS CBT can be delivered safely via the internet to patients with body dysmorphic disorder. BDD-NET has the potential to increase access to evidence based psychiatric care for this mental disorder, in line with NICE priority recommendations. It could be particularly useful in a stepped care approach, in which general practitioner or other mental health professionals can offer treatment to people with mild to moderate symptoms at low risk of suicide.Funding Agencies|Stockholm County Council; Karolinska Institutet; Swedish Research Council [K2013-61X-22168-01-3]; Swedish Society of Medicine (Soderstromska Konigska sjukhemmet) [SLS3B4451]</p

Empirically defining treatment response and remission in body dysmorphic disorder using a short self-report instrument

Determining response or remission status in body dysmorphic disorder (BDD) usually requires a lengthy interview with a trained clinician. This study sought to establish empirically derived cut-offs to define treatment response and remission in BDD using a brief self-reported instrument, the Appearance Anxiety Inventory (AAI). Results from three clinical trials of BDD were pooled to create a sample of 123 individuals who had received cognitive behaviour therapy for BDD, delivered via the internet. The AAI was compared to gold-standard criteria for response and remission in BDD, based on the clinician-administered Yale-Brown Obsessive Compulsive Scale, modified for BDD (BDD-YBOCS), and evaluated using signal detection analysis. The results showed that a ≥40% reduction on the AAI best corresponded to treatment response, with a sensitivity of 0.71 and a specificity of 0.84. A score ≤13 at post-treatment was the optimal cut-off in determining full or partial remission from BDD, with a sensitivity of 0.75 and a specificity of 0.88. These findings provide benchmarks for using the AAI in BDD treatment evaluation when resource-intensive measures administered by clinicians are not feasible