Mental Health

Probability of Full Recovery From Body Dysmorphic Disorder Good Over Time

 Over Time

With enough time, and proper treatment, many patients with body dysmorphic disorder (BDD) are likely to recover and not relapse, new research suggests.

In a cohort study examining 514 patients from the Harvard/Brown Anxiety Research Project (HARP) over 8 years, the 22 found to have BDD had a 76% probability of full recovery and only a 14% probability of recurrence after recovery. However, in many of the cases remission took more than 5 years.

“I think the findings were very encouraging because of the high probability found of fully remitting from this disorder,” study investigator Katharine A. Phillips, MD, professor of psychiatry and human behavior at the Warren Alpert Medical School of Brown University and director of the Body Dysmorphic Disorder Program at Rhode Island Hospital in Providence, told Medscape Medical News.

 

 Over Time


January 14, 2011 — With enough time, and proper treatment, many patients with body dysmorphic disorder (BDD) are likely to recover and not relapse, new research suggests.

In a cohort study examining 514 patients from the Harvard/Brown Anxiety Research Project (HARP) over 8 years, the 22 found to have BDD had a 76% probability of full recovery and only a 14% probability of recurrence after recovery. However, in many of the cases remission took more than 5 years.

“I think the findings were very encouraging because of the high probability found of fully remitting from this disorder,” study investigator Katharine A. Phillips, MD, professor of psychiatry and human behavior at the Warren Alpert Medical School of Brown University and director of the Body Dysmorphic Disorder Program at Rhode Island Hospital in Providence, told Medscape Medical News.

Dr. Katharine A. Phillips

“On the other hand, remission was defined only as symptom-free for at least 8 consecutive weeks. So although a high proportion of participants were free of symptoms for that time, it doesn’t mean they were symptom free for the entire follow-up period. And for many others, it took a while for recovery to occur,” said Dr. Phillips.

The investigators point out that this is the longest-running study to date tracking patients with the disorder. Those with BDD “loathe their appearance” and obsess over nonexistent or slight defects in their physical appearance.

“We want to make people aware of BDD — aware that it exists and that it’s a real mental illness. These people should be assessed very carefully and steered toward treatment very quickly,” said Martin B. Keller, MD, from Brown University and principal investigator of HARP, in a release.

“With all the studies we have done that focused on the treatments recommended for BDD, which are cognitive-behavioral therapy and serotonin reuptake inhibitors, the majority of patients improve. So if you use 1 of those 2 recommended treatments, you’re likely to do well,” added Dr. Phillips.

The study is published in the January issue of The Journal of Nervous and Mental Disease.

Under-recognized

Dr. Phillips noted that this disorder “has been described for more than a century” and although it is becoming more common, is often severe, and is associated with a high suicide attempt rate, it is still under-recognized and hasn’t been the focus of much research.

“It’s just very important for clinicians and patients to know something about the course of the illness and what expected rates of recurrence and relapse are. And very little is known about how people with [BDD] do over time.”

She noted that many patients are very secretive about symptoms, or, if they do talk about them, they worry that they will be considered silly or vain for worrying about their appearance.

“Many patients are reluctant to spontaneously reveal symptoms to clinicians. But I think if they’re asked, they will talk about it and are relieved to talk about it,” said Dr. Phillips.

The investigators evaluated 514 patients over the age of 18 years from HARP, a program that has been conducting prospective research on patients diagnosed with an anxiety disorder for more than 20 years.

The Global Assessment Scale was used to assess overall psychosocial functioning at enrollment, and the presence of BDD was determined by using the BDD Diagnostic Module interview, given beginning in HARP’s fifth year.

Severity of BDD symptoms was assessed during annual follow-up interviews by using the Longitudinal Interval Follow-up Evaluation Psychiatric Status Rating scale.

Recurrence was defined as “the occurrence of symptoms at a Psychiatric Status Rating level of 5 or greater for 4 consecutive weeks after recovery.”

Significant Improvement

At the study’s initial assessment, 22 of the patients (4.3%) were found to have lifetime BDD and 17 (3.3%) had current BDD.

Those with lifetime BDD (mean age, 38.1 years; 72.7% female; mean age at onset, 17.3 years) had significantly lower Global Assessment Scale scores, indicating poorer functioning, than those without BDD (mean age, 40.4 years; 68.9% female; P = .043).

In addition, “more than half of the individuals with BDD had BDD beliefs that were characterized by poor insight (45.5%) or delusional thinking (9.1%),” report the researchers.

Fifteen participants were evaluated through all 8 years of follow-up. Probability of full recovery was 0.76 over the 8 years and recurrence probability after recovery was 0.14.

“Of the 10 participants who recovered, only 1 subsequently suffered recurrence of BDD,” the study authors write.

Dr. Phillips added that at the 1-year follow-up, “more than 90% had not been free of their BDD symptoms for at least 8 weeks over the past year. And at the 4-year mark, more than 60% had had chronic BDD for all of those 4 years.”

However, remission probability significantly improved after 5 years.

Recovery Curve “Steep”

“The recovery curve is steep [between years 1 and 2], then relatively stable, with another steep slope between years 5 and 6 before levelling off again,” the investigators write.

“Compared to what we expected based on a prior longitudinal study of BDD, there was a surprisingly high overall recovery rate and a low recurrence rate in the present study,” said lead author Andri Bjornsson, PhD, a postdoctorate research fellow at Brown and the BBD program at Rhode Island Hospital, in a release.

The investigators note that this unexpected finding may be related to the fact that patients in prior studies had especially severe cases of the disease but the patients with BDD in this analysis were identified through an anxiety study and thus had more subtle cases of the disorder.

The authors add that study limitations include the small number of patients with the condition. In addition, because “participants were ascertained for anxiety disorders, it is not clear whether these results can be generalized to other populations of individuals with BDD.”

“Future studies on the course of BDD are greatly needed, with larger samples and in different settings,” write the researchers.

Overall, “I think it’s helpful for clinicians to be aware that some of these people can do very well over time and others have quite chronic symptoms,” said Dr. Phillips.

“I think the most important thing is for clinicians to be aware that BDD exists, and if treated appropriately, many of these patients will have periods of improvement in their symptoms. I think these are encouraging findings,” she added.

Unanswered Questions

“It’s good in general that these types of studies are being done because we really don’t know that much about the longitudinal course of [BDD] and it’s important for us to understand what happens over time,” Jamie D. Feusner, MD, assistant professor of psychiatry at the Semel Institute for Neuroscience and Human Behavior at the University of California, Los Angeles (UCLA), and director of UCLA’s Body Dysmorphic Disorder Research Program.

Dr. Jamie D. Feusner

“In that way, I think this was a really good study but it left open a lot of questions. And I think it’s pretty hard to interpret and understand what was happening in this study mainly because there were so few subjects,” he continued.

Dr. Feusner also noted concerns that the participants “were part of an anxiety assessment” and so BDD wasn’t their primary diagnosis.

“The authors do address that these samples may not be representative of other samples that focused specifically on BDD. So these people had BDD symptoms but perhaps they were related to other anxiety problems.

“For example, those with a social phobia are self-conscious in social situations, are anxious, and sometimes have BDD symptoms. Those with [obsessive-compulsive disorder] often have BDD symptoms that are not their primary problem but are milder and may be part of a secondary symptom cluster,” he said.

He added that the rates found for remission were “surprisingly high” and different from those found in Dr. Phillips’ previous longitudinal study on this disorder (J Nerv Ment Dis. 2005;193:564-567).

“This was also different from my clinical experience that without treatment, this seems to be a chronic disorder. Most of the patients I see that are older and have this disorder have had it since adolescence. When they’re treated, I’ve seen that they do quite well and will respond at least partially to medication and cognitive-behavioral therapy,” said Dr. Feusner.

“However, I didn’t see information included in this paper on whether the participants were being treated and if they were, what was used, when were they treated, and was it for BDD or to treat the anxiety disorder?”

Need for Screening

He noted that many of the first-line treatments for anxiety, such as serotonin reuptake inhibitors, can also treat symptoms of BDD in the right dose. “So while the investigators were treating the anxiety, the BDD symptoms might have gotten better.”

Dr. Feusner said he’d like to see more research in this area.

“In general, I think it would be good to understand more naturalistically in people who have primary BDD problems what their course is. So in essence, a replication of what Katharine Phillips’ earlier study did. I think that would address some of these variables that leave the interpretation of this one so open.”

He added that it would also be interesting to follow up and compare patients treated with those not treated at all.

“I understand it’s difficult to do follow-up studies, but it would be good to understand what happens from adolescence to 20 years later. It would also be good to have different definitions of remission and testing different time intervals.”

“Sort of a hidden point in this study is that 3.3% of the overall participants recruited from psychiatric clinics had [current] BDD. People don’t often screen for this disorder in clinics, and patients often don’t talk about their appearance concerns, not realizing that it’s a psychiatric concern. That 3% is not a trivial number, and I think clinicians should definitely consider screening for this,” concluded Dr. Feusner.

The study was funded by grants from the National Institute of Mental Health. The study authors and Dr. Feusner have disclosed no relevant financial relationships.

Source:

Deborah Brauser

J Nerv Ment Dis. 2011;199:55-57. Abstract

Medscape Medical News © 2011 WebMD, LLC

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