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. Author manuscript; available in PMC: 2023 May 1.
Published in final edited form as: Behav Ther. 2021 Dec 24;53(3):521–534. doi: 10.1016/j.beth.2021.12.006

An evaluation of the Body Dysmorphic Disorder Symptom Scale as a measure of treatment response and remission in psychotherapy and medication trials

Berta J Summers 1,2, Susanne S Hoeppner 2, Clare C Beatty 2,3, Mark A Blais 2, Jennifer L Greenberg 2, Katharine A Phillips 4,5, Sabine Wilhelm 2
PMCID: PMC9046685  NIHMSID: NIHMS1767168  PMID: 35473654

Abstract

The Body Dysmorphic Disorder Symptom Scale (BDD-SS) is a self-report tool that captures an array of representative behavioral and cognitive symptoms commonly displayed by individuals with BDD. The BDD-SS is regularly used among experts in the field, though its utility as a measure of treatment response has not yet been formally evaluated. Results from two clinical trials of BDD treatment were pooled from an archived database to create a sample of 220 BDD participants who received either psychosocial or medication-based interventions for BDD. We used baseline BDD-SS scores to describe psychometric properties, baseline correlations with other scales to examine the content validity of the BDD-SS, and longitudinal symptom data to evaluate capacity to detect clinically relevant change. Results indicated that the BDD-SS has good psychometric properties and is able to detect symptom change over time, although it showed lower rates of reliable change with treatment relative to the gold standard rater-administered Yale-Brown Obsessive-Compulsive Scale Modified for BDD (BDD-YBOCS). The BDD-SS offers meaningful information about treatment response in a self-report format and may be particularly useful to employ in clinical practice settings as a means of gathering symptom and treatment response data via self-report when rater-administered interviews are not feasible, although it may underestimate the extent of improvement with treatment.

Keywords: body dysmorphic disorder, body dysmorphic disorder symptom scale, treatment response, reliable change, psychometric validation

Introduction

Body dysmorphic disorder (BDD) is a sometimes debilitating psychiatric condition that is classified as an obsessive-compulsive and related disorder. BDD is characterized by time-consuming preoccupations with a perceived (or slight) flaw in one’s physical appearance that cause clinically significant distress or impairment in functioning. The most common appearance concerns focus on perceived defects of the skin, hair, or nose (American Psychiatric Association, 2013; Phillips et al., 2005). In an effort to hide, check, improve, or obtain reassurance about their appearance concerns, individuals with BDD engage in compulsive appearance-related activities such as excessive mirror checking, grooming, camouflaging, and reassurance-seeking, as well as social avoidance (Phillips, 2017). BDD is a complex disorder that is widely under-recognized and commonly misdiagnosed (Phillips, 2017). Accurate symptom assessment typically requires a thorough interview by a trained clinician who is familiar with these patients and is able to rule out other diagnoses that can mimic BDD symptoms (e.g., eating disorders, social anxiety disorder, obsessive-compulsive disorder, psychotic disorders).

The Yale-Brown Obsessive-Compulsive Scale Modified for BDD (BDD-YBOCS; Phillips et al., 1997; Phillips et al., 2014) is regarded as the gold-standard BDD severity measure and is the most commonly used means of assessing symptom change over the course of treatment in clinical trials. The BDD-YBOCS is a 12-item highly reliable, valid, and effective means of evaluating BDD severity and treatment response, with strong sensitivity to change (Phillips et al., 1997; Phillips et al., 2014). However, the semi-structured interview format requires valuable rater time to administer correctly, and the instrument has not been validated for use as a self-report measure (Phillips et al., 2014). Furthermore, items of the BDD-YBOCS broadly capture distress and interference due to appearance-related obsessions and compulsions without identifying severity of individual symptoms characteristic of the population. This approach has some advantages; for example, it does not count symptoms that are not always present, or often not present, in people with BDD toward a severity score, which might in theory make it better able to detect change with treatment.

The field is in need of valid and reliable self-report instruments to better assess the varied and complex symptom phenomenology of BDD. Self-report measures most commonly used with these populations such as the Body Dysmorphic Disorder Questionnaire (BDDQ; Phillips, Atala, & Pope, 1995), the Dysmorphic Concern Questionnaire (DCQ; Mancuso, Knoesen, & Castle, 2010), and the Body Image Disturbance Questionnaire (BIDQ; Cash, 2008; Cash, Phillips, Santos, & Hrabosky, 2004) are useful in screening for BDD, but do not offer a rich description of the individual’s clinical presentation. Importantly, these tools do not capture ritualistic behaviors characteristic of BDD, which were added to BDD’s diagnostic criteria for DSM-5 (although this addition was not intended to change caseness [Phillips et al., 2010], and thus these measures can be used to screen for both DSM-5-defined and DSM-IV-defined BDD). Other relevant self-report measures assess the broader construct of appearance dissatisfaction (e.g., Appearance Schemas Inventory-Revised [Cash, 2008, Cash, Melnyk, & Hrabosky, 2004]; Multidimensional Body-Self Relations Questionnaire [Brown, Cash, & Mikulka, 1990]), though they are not specific to BDD. Given this gap, some researchers have adapted BDD-specific rater-administered measures for self-report, including self-report versions of the BDD-YBOCS and Body Dysmorphic Disorder Examination (BDDE; Rosen & Reiter, 1994); however, these measures have not been formally validated for such a use and thus the psychometric properties of these adaptations are unknown.

Further, while in clinical practice the first three items of the BDD-YBOCS can be effective for tracking BDD severity (Phillips, 2005), a well-validated disorder-specific self-report measure that is able to detect clinically meaningful nuances in BDD symptom change would offer a useful complement to rater-administered measures, particularly in large clinical trials for which regulatory approval is not being sought for a treatment. The availability of a well-constructed self-report instrument could also minimize rater burden, as it is sometimes impractical to dedicate additional clinician or rater effort to recurring (e.g., weekly) assessments in research settings or use limited session time in clinical settings towards semi-structured symptom evaluation. Further, such a tool may also be used to detect large changes in research or population health tracking contexts where rater-administered tools may not be feasible to implement (e.g., internet- or mobile app-delivered treatment).

The BDD-Symptom Scale (BDD-SS; Wilhelm et al., 2016) is a relatively new self-report symptom assessment designed by leading experts in the field of BDD research. Given that extant measures validated for self-report are largely used for screening purposes, the BDD-SS expands beyond what these tools capture by individually rating a wide range of key behavioral and cognitive symptoms (54 symptoms in total) that map on to extant cognitive-behavioral models of BDD (e.g., Neziroglu et al., 2008; Veale, 2004; Wilhelm et al., 2013). These models collectively posit that the disorder is maintained by a cycle of maladaptive appearance-related rituals, avoidance behaviors, and beliefs about appearance. The measure groups disorder features together into seven conceptually related clusters (i.e., checking, grooming, weight/shape-related, hair-pulling/skin-picking, surgery/dermatology seeking, avoidance, and maladaptive BDD-related beliefs), and respondents rate the severity of each symptom theme over the past week. The initial psychometric exploration of the BDD-SS in a sample of 99 BDD patients was promising, revealing that the measure showed moderate reliability, convergent and discriminant validity (Wilhelm et al., 2016). Importantly, measurement-based care—that is, routine objective assessment of clinical outcomes—is an essential element of evidenced-based practice for the treatment of psychiatric and medical illnesses (Fortney et al., 2017). The BDD-SS is commonly used for this purpose in clinical settings among clinicians who specialize in the treatment of BDD (i.e., to assess and monitor patient progress); however, it has not yet been formally evaluated as a measure of treatment response in clinical or research settings.

To this end, the current study aimed to replicate and extend the previous evaluation of the BDD-SS in a larger treatment-seeking sample. Secondary analyses were conducted using data from two large clinical trials for BDD (total N = 220): a psychosocial intervention trial comparing the efficacy of cognitive-behavioral therapy (CBT) and supportive psychotherapy (SPT; Wilhelm et al., 2019), and a pharmacotherapy trial testing the efficacy of the serotonin-reuptake inhibitor escitalopram (Phillips et al., 2016). We first sought to replicate and broaden the findings of the original psychometric paper (Wilhelm et al., 2016) by exploring the psychometric characteristics of the BDD-SS and its correlations with measures of BDD severity, insight into BDD-related beliefs, quality of life, and depression. Further, we sought to examine the utility of the BDD-SS as a treatment-outcome measure by testing change over time and detection of reliable change improvements compared to the gold-standard, rater-administered BDD-YBOCS.

Methods

Participants and procedures

Our analysis included data from 220 participants enrolled in either one of two treatment studies for BDD that were conducted at two academic medical centers: Massachusetts General Hospital (MGH; affiliated with Harvard Medical School) and Butler Hospital (BH) or Rhode Island Hospital (RIH; both affiliated with the Alpert Medical School of Brown University). Data were collected at both sites for both studies; of note, one study (i.e., CBT vs. SPT) was transferred from BH to Rhode Island Hospital (RIH) part-way through data collection, as the Principal Investigator changed institutions. The institutional review board at each site reviewed and approved study procedures; in accordance with the Declaration of Helsinki, all participants completed a thorough informed consent process in advance of enrolling.

The first study was a relapse prevention trial of escitalopram for BDD (n = 100; Phillips et al., 2016). The study involved two phases: phase I included open-label treatment with escitalopram for 14 weeks (up to 30 mg/day), and phase II included a double-blind placebo-controlled discontinuation phase, in which escitalopram responders were randomized to either continue treatment with escitalopram or switch to pill placebo for an additional 6 months. The current manuscript uses data from phase I. The second study examined the efficacy of CBT for BDD, the most widely studied and empirically supported psychosocial treatment for BDD, in comparison to enhanced SPT (n = 120; Wilhelm et al., 2019); SPT is the most widely received psychotherapy for BDD in the community (Phillips, Menard, et al., 2013). Participants received 22 60-minute sessions of individual therapy, at either hospital, over 24 weeks.

Detailed descriptions of the inclusion and exclusion criteria for each study, and a thorough description of the samples (e.g., clinical and demographic characteristics), are outlined in the main outcome papers (Phillips et al., 2016; Wilhelm et al., 2019). The two clinical trials varied only slightly with regard to inclusion criteria; the primary inclusion criteria for both clinical trials were: (a) age 18 years or older, (b) a diagnosis of BDD (required to be the primary diagnosis in the CBT study), as determined by The Structured Clinical Interview for the DSM-IV Patient Version (SCID-I/P; First et al., 2002), and (c) a score of ≥ 24 on the BDD-YBOCS (indicating BDD symptoms of at least moderate severity; Phillips et al., 1997). Across the two studies, exclusion criteria included (but were not limited to): (a) DSM-IV lifetime bipolar disorder (escitalopram study) or current mania (CBT vs. SPT study), psychotic disorder, current substance abuse/dependence (or borderline personality disorder for the CBT vs. SPT study), (b) acute suicidality, (c) cognitive impairment (e.g., dementia, brain damage), (d) recent changes in psychotropic medication (CBT vs. SPT study) or use of any concurrent psychotropic medication or previous allergic reaction to escitalopram or citalopram for the medication study), (e) current participation in psychotherapy (or having engaged in 10 or more sessions of CBT for BDD for the CBT vs. SPT study); and (f) body image concerns accounted for primarily by an eating disorder or weight concerns. Both studies also excluded individuals who displayed any clinical features requiring a higher level of care. Study procedures were approved by the Institutional Review Boards responsible for overseeing research at each respective study site.

Rater-administered measures

Yale-Brown Obsessive-Compulsive Scale Modified for BDD (BDD-YBOCS; Phillips et al., 1997).

The BDD-YBOCS is a modified version of the Yale-Brown Obsessive-Compulsive Scale (Goodman et al., 1989) for obsessive-compulsive disorder that assesses BDD severity over the past week. The semi-structured rater-administered measure contains 12 items, each scored on a 5-point scale from 0 (least severe) to 4 (most severe). The first five items assess the following aspects of BDD-related preoccupations/obsessions (all BDD preoccupations/obsessions combined): time spent per day, distress due to BDD preoccupations, interference in functioning due to BDD preoccupations, and resistance of and control over BDD preoccupations. Items 6-10 assess BDD rituals (i.e., compulsions, repetitive behaviors; all BDD rituals combined are rated), such as excessive mirror checking, grooming, skin picking, measuring body parts). Item 11 assesses insight/delusionality of BDD beliefs (such as “I am ugly.”), and item 12 assesses avoidance of situations or activities due to BDD preoccupations and repetitive behaviors (all situations or activities combined). The total score is calculated by summing items 1-12 (range 0 - 48), with higher scores indicating more severe BDD symptoms. The BDD-YBOCS has previously demonstrated excellent interrater reliability (Intraclass Correlation for total score [ICC]=.99 and .97), test-retest reliability (ICC=.88 and .93), good internal consistency (α=.80 and .92), convergent validity (r=.82 with the Body Dysmorphic Disorder Examination [BDDE; Rosen & Reiter, 1996]), discriminant validity (r=.24 with the Brief Social Phobia Scale [BSPS]; Davidson et al., 1997) and sensitivity to change with treatment (in a pooled analysis of data from three SRI treatment studies, mean BDD-YBOCS total score decreased significantly, by 43.5% from baseline to post-treatment; Phillips et al., 1997; Phillips et al., 2014). In the present study, the BDD-YBOCS demonstrated good internal consistency for the total score, ranging from α=.71 at baseline to α=.94 at week 14/16 across both study samples (α=.71).

Brown Assessment of Beliefs Scale (BABS; Eisen et al., 1998)

The BABS is a 7-item semi-structured rater-administered instrument that assesses past week insight/delusionality of inaccurate beliefs (Eisen et al., 1998, Phillips, Hart, et al., 2013). When used for BDD, it assesses the individual’s global belief regarding their appearance flaws (e.g., “I look abnormal”). Each item is scored on a scale of 0 to 4, and the total score is calculated by summing the first 6 items (the 7th item evaluates ideas/delusions of reference).

Total scores range from 0-24, with lower scores indicating better insight. The measure classifies disorder-related insight both dimensionally and categorically, where categorical total score ranges are 0-3 = “excellent insight”, 4-7 = “good insight”, 8-12 = “fair insight”, 13-17 = “poor insight,” and a total score of ≥18 plus a score of 4 on item 1 (i.e., complete conviction) = “absent insight/delusional beliefs.” The BABS has demonstrated strong psychometric properties, including excellent test-retest reliability (ICCs for total score = 0.95 and 0.77) and interrater reliability (ICCs for total score = 0.96), good internal consistency (α=.87), convergent validity (r=.56-.82 with measures of delusions) and divergent validity (r=.20-.32 with scales measuring other psychiatric symptoms), and sensitivity to change with treatment (assessed in a multicenter treatment study of sertraline for OCD; mean BABS score decreased by 51%; Eisen et al., 1998, Phillips, Hart, et al., 2013). In the present study, the internal consistency for the BABS was good, ranging from α=.73 at baseline to α=.90 at week 14/16.

Self-report measures

Body Dysmorphic Disorder Symptom Scale (BDD-SS; Wilhelm et al., 2016)

The BDD-SS assesses the presence and severity of common BDD symptom clusters, including: checking rituals, grooming rituals, weight/shape-related rituals, hair-pulling/skin-picking rituals, surgery/dermatology seeking rituals, avoidance, and dysfunctional BDD-related cognitions. The measure contains 54 symptoms divided into seven conceptually similar symptom clusters. Grouping like-features together optimizes specificity while streamlining the assessment approach and limiting administrative burden (i.e., measure typically requires less than 10 minutes to complete). Patients are instructed to endorse which of the symptoms they experienced over the past-week (Y/N), and the number of symptoms is summed to create a total symptom score. For each cluster in which at least one symptom is endorsed, participants also rate the overall (combined) symptom severity of that cluster on a Likert-scale from 0 (no problem) to 10 (very severe). Participants are asked to evaluate the subjective severity of the whole symptom cluster in terms of the total frequency and amount of distress they experienced during the past week from all symptoms in the cluster, not the average ratings across symptoms within the cluster. The cluster severity ratings are then summed for a total severity score. The BDD-SS has shown good internal consistency (KR-20=.81 [BDD-SS Symptom scale] and α=.75 [BDD-SS Severity scale]), moderate convergent validity (r=.46 [BDD-SS severity score] and r=.66 [BDD-SS symptom score] with the BDD-YBOCS), and moderate discriminant validity (r=.26 [BDD-SS severity score] and r=.32 [BDD-SS symptom score] with the BDI-II; Wilhelm et al., 2016).

The Quality of Life, Enjoyment, and Satisfaction Questionnaire Short-Form (Q-LES-Q-SF; Endicott et al., 1993)

The Q-LES-Q-SF is a widely used 16-item self-report measure that assesses participants’ subjective quality of life during the past week, comprised of 14 items tapping a broad range of life issues (social relationships, leisure activities, household duties, school, work, emotional well-being and physical health), and two additional items assessing satisfaction with current medication (if taking medication), and overall life satisfaction. The current study analyses only used the 14 primary items for scoring (the short form version). Each item uses a Likert scale, ranging from 1 (very poor satisfaction) to 5 (very good satisfaction). Total quality of life scores are calculated by summing the first 14 items, with a maximum possible score of 70 (higher scores indicate higher quality of life or satisfaction). The raw score is converted to a percentage of the maximum possible score. The Q-LES-Q-SF has demonstrated strong psychometric properties, including high internal consistency (α=.90), good test-retest reliability (r=.74), and convergent validity (r=.43-.89 with scales measuring global functioning and improvement) (Endicott et al., 1993; Rapaport et al., 2005; Stevanovic, 2011). The Q-LES-Q-SF demonstrated good internal consistency in this sample (α range: .87 at baseline to .92 at week 14/16—i.e., the study-specific assessment taking place 14 or 16 weeks after initial enrollment).

Beck Depression Inventory-II (BDI-II; Beck et al., 1996)

The BDI-II is a 21-item self-report questionnaire that assesses the severity of depressive symptomatology over the past two weeks. Each item has a sequence of four self-evaluative statements that are scored from 0 to 3 (e.g., 0 = I do not feel sad, 3 = I am so sad or unhappy that I can’t stand it). Items assess particular depressive symptoms, such as sadness, pessimism, past failure, self-dislike, etc. Sum scores range from 0 to 63, with higher total scores reflecting more severe depressive symptomatology (suggested cutoff scores to categorize depression severity include: 0-13 = “minimal,” 14-19 = “mild,” 20-28 = “moderate,” and 29-63 = “severe”). The BDI-II has demonstrated strong psychometric properties, including excellent internal consistency (α=.92), test–retest reliability (r=.93) and strong concurrent and discriminant validity (r= .71 with the revised Hamilton Psychiatric Rating Scale for Depression and r=.47 with the revised Hamilton Rating Scale for Anxiety; Beck et al., 1996; Riskind et al., 1987). In the present studies, the internal consistency was excellent (α range: .93 at baseline to .95 at week 14/16).

Data analytic plan

The data presented in the current manuscript are based on an appended set of patient-level data from both parent studies. Five participants from the appended dataset were excluded due to missing BDD-SS data at baseline. We used Chi-square and t-tests to examine baseline characteristics and determine whether samples differed in any meaningful way. Due to the differences in the frequency of assessment visits in both studies, we used only the monthly assessments common to both, including baseline, 4-, 8-, and 12-week visits, as well as the last visit in the open-label escitalopram study phase (week 14) and the nearest corresponding assessment in the randomized therapy study (week 16). Measures of internal consistency (i.e., Cronbach’s α and the special case of Cronbach’s α for binary data, the Kuder–Richardson Formula 20 (KR-20) – both labelled α herein for simplicity) were calculated using all available data at each assessment visit. Pearson correlations between symptom measures (i.e., BDD-SS total severity scores, BDD-SS total symptom scores, BDD-YBOCS total scores, BABS total scores, BDI-II total scores, and Q-LES-Q-SF percent scores) were assessed using all available data for each measure at both baseline (n range: 185-215) and week 14/16 (n range: 151-163). To assess symptom change over time in each treatment at each site for the BDD-YBOCS, as well as the BDD-SS total severity and total symptom scores, we used linear latent growth curve models (LGMs; i.e., random intercept, random slope models) of all available data in the intent-to-treat samples with site and the interaction of treatment by site by time as fixed effects. We included site effects in the model to better estimate the variability of treatment pre- to post-effect sizes in light of previously identified site differences in the CBT study (Wilhelm et al., 2019). The effect size of the pre-to-post change in each treatment-by-site group was estimated as dLGM=β*(time)/SDbsl, where β was the estimated weekly change coefficient, time was set to 14 weeks for all treatment groups, and SDbsl was the baseline standard deviation of the outcome in each group. We estimated the variability of each outcome at baseline with the coefficient of variation (CVbsl). We then calculated reliable change indices (RCI; Jacobson & Truax, 1991) for each outcome measure for each patient who completed the week 14/16 assessment and determined the percentage of trial ‘completers’ who had achieved clinically reliable change (i.e., RCI<−1.96). The measurement error for each measure was based on the baseline standard deviations and baseline Cronbach’s alphas for the whole sample for each outcome. All analyses were performed using SAS (Version 9.4).

Results

Our combined sample of treatment-seeking patients with BDD (n=220) was predominantly female (n=155; 72.1%), white (n=184; 85.6%), and non-Hispanic (n=191; 90.5%) with a mean (SD) age of 33.6 (12.8). The majority of participants were single (n=134; 62.3%) as opposed to married (n=41; 19.1%) or of other marital status (n=40; 18.6%, including widowed, divorced, or separated). At baseline, the overall sample endorsed moderate-severe BDD symptom severity (BDD-YBOCS: 32.6 (5.0)), overall poor insight regarding their BDD beliefs (BABS: 15.9 (4.6)), and poor quality of life (Q-LES-Q-SF: 49.9 (15.6)). Insight into BDD beliefs was fair for 19.6% (n=35), poor for 50.8% (n=91), absent for 25.7% (i.e., delusional beliefs; n=46), and good or excellent for only a few (n=7, 3.9%). The majority of participants reported moderate (n = 55; 25.8%) to severe (n = 63; 29.6%) depression symptoms at baseline, as measured by the BDI-II. No significant differences were detected in the demographic characteristics and baseline severity of BDD (BDD-YBOCS) or other symptoms (BABS, Q-LES-Q-SF, BDI-II) of the samples from the two parent studies (all p>.05), although the open-label escitalopram study trended towards a larger percentage of male study participants (n=33, 34.4%) than the therapy study (n=27, 22.7%; p=.0576).

Descriptive Statistics and Internal Consistency of Symptom Categories

There was a wide range in the endorsement rate of individual symptoms (Table 1), but the internal consistency of the BDD-SS summary scores was good: BDD-SS total symptom score: α=.84; and BDD-SS total severity score: α=.83.

Table 1.

Endorsement rates of the BDD-SS symptoms.

Category, symptom n (%)
Checking
 Checking or inspecting certain parts of my body 205 95.3
 Measuring or counting body part 52 24.2
 Touching or feeling body part 178 82.8
 Asking questions about my appearance over and over again, even though I understood the answer the first time 101 47.0
 Mentally reviewing past events, conversations, and actions to find out how people reacted to my appearance 159 74.0
 Checking mirrors repeatedly 188 87.4
 Comparing my appearance to others’ appearance (in person, in pictures or in the media) 201 93.9
 Scrutinizing others 128 59.8
Grooming
 Grooming myself longer than necessary 142 66.0
 Spending a lot of money to improve my appearance 75 35.0
 Tanning 30 14.0
 Combing hair 94 43.7
 Applying makeup 122 57.0
 Shaving 106 49.5
 Changing clothes 139 64.7
Weight/Shape
 Lifting Weights 54 25.1
 Using steroids 0 0.0
 Exercising excessively 34 15.8
 Eating in special ways 71 33.0
Picking/Plucking
 Skin picking 96 45.3
 Pulling or plucking hair 62 29.1
Avoidance
 Avoiding mirrors or reflective surfaces 88 41.1
 Avoiding social situations where family, friends, acquaintances, co-workers are present (work, parties, family gatherings, meetings, talking in small groups, having a conversation, dating, speaking to boss or supervisor) 154 72.0
 Avoiding public areas (shopping, stores, busy streets, restaurants, movies, buses, trains, parks, waiting in lines, public restrooms) 98 45.6
 Avoiding intimate or close physical contact with others (sexual activity, hugging, kissing, dancing, talking closely) 134 62.3
 Avoiding physical activities like exercise or recreation because of concern about appearance 106 49.3
 Avoiding being seen nude or with few clothes 145 67.4
 Hiding appearance (with make-up, clothing, hairstyle, jewelry, hats, hands, or body position) 191 88.8
 Changing appearance (getting a haircut) 59 27.6
 Discounting compliments 162 75.3
 Becoming upset by compliments 91 42.5
Surgical/Dermatological
 Visiting plastic surgeons, dermatologists or dentists to improve appearance 33 15.4
 Obtaining cosmetic surgery 8 3.7
 Using medications or topical treatments to correct defects (e.g., skin, baldness) 89 41.6
 Applying self-surgery 10 4.7
Cognitions
 I believe others are thinking of my appearance 183 85.5
 The first thing people notice about me is what’s wrong with my appearance 162 75.3
 I think that others are staring at or talking about me 123 57.2
 I believe others treat me differently because of my physical defects 103 48.1
 If my appearance is defective, I am worthless 99 46.0
 If my appearance is defective, I will end up alone and isolated 121 56.3
 If my appearance is defective, I am helpless 101 47.0
 No one can like me as long as I look the way I do 104 48.4
 If my appearance is defective, I am unlovable 114 53.0
 I must look perfect 123 57.5
 I look defective or abnormal 167 78.0
 I am an unattractive person 171 79.9
 What I look like is an important part of who I am 188 87.4
 Outward appearance is a sign of the inner person 89 41.6
 No one else my age looks as bad as I do 82 38.1
 If I could look just the way I wish, I would be much happier 203 94.4
 People would like me less if they knew what I really looked like 132 61.4
 My appearance is more important than my personality, intelligence, values, skills, how I relate to others, and my performance at work or in other settings 78 36.3
 If I learn to accept myself, I’ll lose my motivation to look better 102 47.4
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The most prevalent symptoms endorsed (>85%) were three checking symptoms (“Checking or inspecting certain parts of my body,” “Checking mirrors repeatedly,” and “Comparing my appearance to others’ appearance”), one avoidance symptom (“Hiding appearance with make-up, clothing, hairstyle, jewelry, hats, hands, or body position)”, and three cognitions (“I believe others are thinking of my appearance”, “What I look like is an important part of who I am”, and “If I could look just the way I wish, I would be much happier”). The symptoms endorsed most rarely (<15%) were one grooming symptom (“Tanning”), one weight/shape symptom (“Using steroids”), and two surgical/dermatological symptoms (“Obtaining cosmetic surgery” and “Applying self-surgery”; Table 1).1 More than 98% of participants endorsed at least one symptom in the checking, avoidance, and cognitions groups, which also tended to have higher severity ratings than the smaller, less frequently endorsed symptom groups of weight/shape, picking/plucking, and surgical/dermatological symptoms (Table 2).

Table 2.

BDD-SS symptom clusters, cluster endorsement, and cluster severity ratings.

Cluster Number of items
 Cluster endorsement and severity ratings
% (n) M (SD)
Checking 8 99.5 (214) 7.1 (2.0)
Grooming 6 93.5 (201) 6.0 (2.4)
Weight/Shape 5 44.2 (95) 5.4 (2.8)
Picking/Plucking 2 54.9 (118) 5.7 (2.5)
Avoidance 10 98.6 (212) 6.8 (2.1)
Surgical/Dermatological 4 44.7 (96) 5.4 (2.4)
Cognitions 19 99.1 (213) 7.3 (2.1)
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Convergent Validity of the BDD-SS Summary Scores

Both the BDD-SS total severity and total symptom scores correlated positively with measures of symptom severity and negatively with quality of life (Table 3). At baseline, when all patients were untreated and met full diagnostic criteria for BDD, both the BDD-SS total severity and total symptoms scores showed moderate positive correlations with the rater-administered measure of BDD symptom severity (i.e., BDD-YBOCS; r = .39 and r= .40) and depression severity (r = .37 and r = .48). These two BDD-SS scales had weaker negative correlations with quality of life at baseline. All of the associations between the BDD-SS total severity and symptom scores with other measures were still present but stronger at follow-up, when there was a mix of remitted and unremitted patients (Table 3).

Table 3.

Correlations between BDD-SS scores with BDD symptom severity scores measured by the BDD-YBOCS, depression severity (BDI-II), and quality of life (Q-LES-Q-SF) at baseline and after 14-16 weeks of treatment.

BDD-SS total severity score BDD-SS total symptom score BDD-YBOCS total score BABS total score BDI-II total score
Baseline (n=215) (n=215) (n=215) (n=185) (n=213)
 BDD-SS total symptom score    0.64 ***
 BDD-YBOCS total score    0.39 ***    0.40 ***
 BABS total score    0.04    0.14    0.43 ***
 BDI-II total score    0.37 ***    0.48 ***    0.42 ***    0.24 **
 Q-LES-Q-SF percent score  −0.28 ***  −0.36 ***  −0.43 ***  −0.33 ***  −0.70 ***
Week 14/16 (n=151) (n=151) (n=158) (n=158) (n=163)
 BDD-SS total symptom score    0.85 ***
 BDD-YBOCS total score    0.79 ***    0.73 ***
 BABS total score    0.52 ***    0.57 ***    0.63 ***
 BDI-II total score    0.65 ***    0.61 ***    0.62 ***    0.39 ***
 Q-LES-Q SF percent score  −0.62 ***  −0.55 ***  −0.69 ***  −0.44 ***  −0.71 ***
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Note.

*

p<.05,

**

p<.001,

***

p<.001;

BDD-SS = Body Dysmorphic Disorder Symptom Scale; BDD-YBOCS = Yale-Brown Obsessive-Compulsive Scale Modified for BDD; BABS = Brown Assessment of Beliefs Scale; BDI-II = Beck Depression Inventory-II; Q-LES-Q-SF = Quality of Life, Enjoyment, and Satisfaction Questionnaire Short Form; not all participants completed all assessments at each time point.

Regarding correlations with the baseline BABS insight/delusionality total score, for the baseline BDD-SS total severity score there was no meaningful correlation (r = .04), for the baseline BDD-SS total symptom score there was a weak and non-significant correlation (r = .14), and both scales showed moderate correlations with BABS scores at follow-up. The correlation between the two established BDD-SS summary scores (i.e., total severity and total symptoms) with each other was moderately strong to strong at both time points (Table 3).

BDD-SS Summary Scores Detection of Change Throughout Treatment

The BDD-SS total severity and total symptom scores changed significantly from pre-treatment to the assessment after 14/16 weeks of treatment, albeit not as strongly as the rater-administered BDD-YBOCS scores (Table 4). The pre- to post estimated within-group effect sizes for BDD-SS total severity scores ranged from −0.49 to −1.56 across sites and treatments (dLGM M±SD: −1.18±0.37), while those of the BDD-SS total symptom scores ranged from −0.44 to −1.48 (dLGM M±SD: −1.10±0.40); meanwhile, the treatment effect sizes estimated based on the BDD-YBOCS ranged from −1.66 to −3.40 (dLGM M±SD: −2.69±0.71) over the same time period (Table 4). The difference in effect sizes by the BDD-SS total severity and total symptom scores versus those detected by the BDD-YBOCS are partially explained by the greater variability of baseline BDD-SS total severity (CV M±SD: 0.31±0.05 across sites and treatments) and BDD-SS total symptom scores (CV M±SD: 0.27±0.04 across sites and treatments) compared to the rater-administered BDD-YBOCS total scores (CV M±SD: 0.15±0.02 across sites and treatments). Using reliable change indices for each outcome identified higher percentages of patients who were classified as having improved by week 14/16 using the BDD-YBOCS (range: 48-89%) than by using either BDD-SS total severity scores (range: 32-76%) or BDD-SS total symptom scores (range: 26-62%; Table 4).

Table 4.

Symptom change over time and baseline variability in three treatment groups (i.e., open-label escitalopram, cognitive behavioral therapy, and supportive psychotherapy) at each of 2 sites.

Change over time estimates (intent-to-treat) Baseline estimates (intent-to-treat) RCI improvement (completers only)
95% 95%
Estimate LCL UCL d LGM Mbsl SDbsl CVbsl % n completers
BDD-YBOCS total scores
CBT MGH −0.94 −1.17 −0.71 −2.62 32.38 5.02 0.16 71% 24
BH/RIH −0.99 −1.26 −0.72 −3.30 33.11 4.21 0.13 88% 17
SPT MGH −0.75 −0.97 −0.52 −2.04 32.25 5.13 0.16 60% 25
BH/RIH −0.45 −0.70 −0.21 −1.66 31.41 3.83 0.12 48% 21
Escitalopram MGH −1.16 −1.36 −0.97 −3.12 32.45 5.22 0.16 83% 36
BH −1.35 −1.55 −1.15 −3.40 33.56 5.55 0.17 89% 35
  BDD-SS total severity scores
CBT MGH −0.89 −1.19 −0.60 −1.30 32.78 9.61 0.29 64% 22
BH/RIH −0.87 −1.19 −0.54 −1.21 33.00 10.06 0.30 41% 17
SPT MGH −0.66 −0.94 −0.37 −1.13 33.94 8.12 0.24 35% 23
BH/RIH −0.40 −0.71 −0.09 −0.49 31.89 11.54 0.36 32% 19
Escitalopram MGH −1.15 −1.42 −0.88 −1.40 36.22 11.50 0.32 58% 36
BH −1.49 −1.76 −1.21 −1.56 37.13 13.37 0.36 76% 34
  BDD-SS total symptom scores
CBT MGH −0.67 −0.89 −0.44 −1.48 29.25 6.30 0.22 59% 22
BH/RIH −0.65 −0.90 −0.40 −1.39 27.29 6.59 0.24 53% 17
SPT MGH −0.44 −0.66 −0.22 −0.79 28.31 7.82 0.28 30% 23
BH/RIH −0.24 −0.48 0.00 −0.44 25.52 7.50 0.29 26% 19
Escitalopram MGH −0.75 −0.96 −0.55 −1.31 28.84 8.03 0.28 56% 36
BH −0.77 −0.98 −0.56 −1.19 28.53 9.05 0.32 62% 34
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Note. BDD-SS = Body Dysmorphic Disorder Symptom Scale; BDD-YBOCS = Yale-Brown Obsessive-Compulsive Scale Modified for BDD; CBT = Cognitive behavioral therapy; SPT = supportive psychotherapy; MGH = Massachusetts General Hospital; BH = Butler Hospital; RIH = Rhode Island Hospital; RCI = reliable change index; dLGM = effect size of the estimated slope over time effect; Mbsl = mean; SDbsl = standard deviation at baseline; CVbsl = coefficient of variation at baseline. Model estimates are for weekly change. The number of people in each treatment by site group were (1) CBT: 32 MGH, 28 BH/RIH; (2) SPT: 32 MGH, 27 BH/RIH; and (3) open-label escitalopram: 51 MGH, 45 BH; for numbers of completers of week 14/16 assessments, see table.

Discussion

The current study represents a secondary analysis of two large treatment outcome studies for BDD in which we sought to replicate and extend extant explorations of the psychometric properties of the BDD-SS, a self-report measure designed to identify and measure the severity of a broad range of symptoms commonly observed in patients with BDD. Further, we examined the potential utility of the BDD-SS as a measure of symptom change over the course of treatment, compared to the gold-standard rater-administered severity measure most commonly used in treatment trials, the BDD-YBOCS.

Samples examined (N = 220) were larger than those of previous explorations of the BDD-SS, with comparable BDD symptom endorsement and severity levels (e.g., N = 99 in Wilhelm et al., 2016). Likewise, the BDD-SS total and severity scores evidenced similar correlations with the BDD-YBOCS, BDI-II, and BABS to those reported previously (Wilhelm et al., 2016). Regarding convergent validity with the BDD-YBOCS, the correlations for the BDD-SS total severity and total symptom scores at baseline (.39 and .40) were significant yet modest for scales that cover most of the same symptoms. These associations were stronger at end-of treatment, perhaps because symptom severity showed a broader range compared to pre-treatment. However, BDD-specific symptom severity correlations (i.e., with the rater-administered BDD-YBOCS) were comparable to those observed with non-BDD symptoms (i.e., depression). On one hand, this finding may suggest a need to further evaluate convergent validity. However, it is important to note that validated self-report measures of BDD symptoms are limited, and multi-method measurement correlations (i.e., self-report vs. rater-administered) seldom exceed r = .30, as the different aspects of construct measurement limits shared variance (Meyer, 2002). Another interpretation of this finding might be that depression is so closely linked to BDD that it may not be an appropriate measure of discriminant validity. Indeed, the current study also showed strong correlations between the BDD-YBOCS (rater administered) and the BDI (depression), which is consistent with prior reports of baseline correlations between the BDD-YBOCS and depression measures (r = .47 with the BDI and r = .53 with the Hamilton Depression Rating Scale; Phillips et al., 1997; Phillips et al., 2014). However, in prior reports the BDD-YBOCS had a higher correlation with another measure of BDD severity, the Body Dysmorphic Disorder Examination (r = .82; Phillips et al., 2014; Rosen & Reiter, 1996) than was found for the BDD-YBOCS and the BDD-SS in the current report. Like depression, quality-of-life (Q-LES-Q-SF) was also found to be related to the BDD-SS in the current study, with the negative association strengthened from baseline to the end of treatment. This is consistent with clinical observations that BDD symptoms usually have a deleterious impact on the individual’s quality of life (Phillips, 2017). Thus, continued efforts to establish discriminant validity of the BDD-SS are needed.

With regard to measuring treatment response, both BDD-SS total severity scores and BDD-SS total symptom scores detected change over time in treated patients. However, the detected within-group effect sizes for these two BDD-SS scales were only about half or less than half of those detected by the gold-standard rater-administered measure (i.e., the BDD-YBOCS) in the same samples. Relatedly, the BDD-SS summary scores identified lower percentages of participants as having achieved reliable change towards improvement. Lower rates of reliable change can reflect differences in the distributions of the measures rather than sensitivity. Of note, the baseline variability of both BDD-SS severity and total symptom scores was approximately twice that of the BDD-YBOCS. This is likely due to the considerable variety of specific symptoms that can be present in this heterogenous disorder, which are individually rated in the BDD-SS (54 items/symptoms, compared to the 12 items in the BDD-YBOCS).

Psychometrically, specificity is increased when domain-specific item count is increased; thus, the BDD-SS may offer greater specificity about symptom type. It is important to note that the approach to symptom measurement and change in these two assessments is different. While the BDD-YBOCS asks about and then combines individual symptoms (e.g., individual rituals, different types of functional impairment) for ratings, the BDD-SS explicitly and individually rates these symptoms (such as specific maladaptive cognitions, subtle rituals such as ‘mental review,’ and more extreme rituals such as conducting ‘self-surgery’). These two approaches both have advantages and disadvantages. For example, the conversation between rater and patient afforded by the BDD-YBOCS might allow for the capture of idiosyncratic symptoms not assessed by the BDD-SS (for example, counting hairs that fall out of one’s head or weighing oneself excessively). Whereas, the BDD-SS individually rates clinically relevant symptoms and more richly captures avoidant behaviors and cognitive symptoms. Clinicians and researchers interested in examining symptom change over time using the BDD-SS might consider symptom-level analyses to characterize treatment outcomes, rather than relying solely on total scores.

Given how heterogenous this condition is, understanding the change in specific symptoms over the course of treatment is highly valuable as it may speak more precisely to the evolution of change (i.e., may help to clarify maintaining factors and treatment mechanisms for the individual) and inform more targeted treatment goals (e.g., if certain symptoms have been unresponsive, a different or adjunctive approach to addressing that feature of the individual’s illness may be warranted). For instance, the BDD-SS requires respondents to indicate the ways in which their appearance concerns limit their day-to-day experiences by providing individual ratings of whether they have avoided specific experiences or situations (e.g., mirrors, social gatherings, public spaces, intimacy or close physical contact, recreational physical activities). Understanding and fading out maladaptive avoidance is a critical element of CBT for BDD; reduction in avoidance is also one of the more observable and impactful signs of progress in treatment. Thus, the BDD-YBOCS total score may be a more clinically informative snapshot, with a greater ability to detect reliable change over time (compared to the total scores produced by the BDD-SS), but the nature and nuanced process of treatment gains may be more richly informed by the evolution of symptom endorsement on the BDD-SS over time. Future research exploring the sensitivity of this measure might employ Receiver-Operating Characteristic (ROC) analysis to further test its performance in detecting treatment response. It is possible that the BDD-SS may evidence greater sensitivity to change in CBT-specific trials, given that this treatment approach specifically involves monitoring and addressing the symptoms outlined within the measure (e.g., rituals and avoidance symptoms targeted via behavioral experiments, exposure, safety behavior fading, while maladaptive cognitions are modified via cognitive restructuring and core belief work). Given that the current evaluation collapsed across CBT, SPT, and medication trials, using ROC analysis to test the sensitivity of the BDD-SS in a large CBT trial may be particularly informative.

Few self-report measures capturing the nuance of BDD symptoms have been formally validated, and the BDD-SS shows promise as a tool to fill this gap. Rater-administered tools can be regarded as more consistent and accurate ratings of relative symptom severity, as the instrument is administered by a trained rater who likely also has a thorough understanding of the condition. However, just as self-report measures can be compromised by bias, raters too can develop expectancy biases or evidence rater “drift” over time necessitating ongoing calibration to maintain reliability; patients may also alter their report of symptoms when speaking with an interviewer due to shame or beliefs about the rater’s expectations (Cook, 2010; Grootendorst, Feeny & Furlong, 1997; Hartman, Forsen, Wallace & Neely, 2002). Self-administered measures such as the BDD-SS therefore provide meaningful additional data to complement rater-administered measures, and vice versa. Few studies have provided the in-depth phenomenological overview of disorder-specific symptoms in a large clinical sample as is provided by the current study. Continued use of this measure to explore the qualitative differences in symptom occurrence across clinical samples, as well as the differences in self-reported and rater-administered BDD symptom assessment could be valuable.

The current study has some limitations worth noting. For instance, the study employed a number of common exclusionary criteria for study enrollment (e.g., active suicidality, a current substance use disorder, primary weight concerns), which can limit the generalizability of results to the totality of patients seeking treatment for BDD. Likewise, though BDD affects men and women at comparable rates, treatment studies such as those represented in the current manuscript often have a higher proportion of women participating than men. In the case of the current study, endorsement of symptoms on the BDD-SS was likely skewed towards common symptoms observed in women, thus limiting the generalizability of results to concerns that are more common in men with BDD. Further, the current study did not include suitable measures of discriminant validity, as depression and quality-of-life are conceptually too closely linked to BDD to serve as pure measures of discriminant validity. To better examine this in future studies, researchers should incorporate questionnaires measuring constructs that have no theoretical relationship with BDD symptoms.

Given that examinations of the BDD-SS are still in their relative infancy, there are a number of additional research opportunities to pursue in this area. For instance, changes in scale administration could produce a more meaningful understanding of symptom ‘intensity’ and improve the utility of the measure more broadly. For example, administering the scale such that participants are asked to rate the severity of each individual symptom—rather than rating severity collapsed by theme—might offer a richer understanding of the symptom expression and improve sensitivity to change over time. Theme-based severity scores could still be calculated with this method by averaging severity ratings of like-symptoms. Other means of improving the measure might include factor-analytic explorations, refinements to the clusters and corresponding symptoms, and/or altering the scoring methodology. For instance, the current summary score is confounded with the number of symptoms endorsed; an individual with few but very severe symptoms may receive a lower total ‘severity’ and ‘symptom’ score relative to an individual who endorses many mild symptoms. Though the BDD-SS as it is currently designed can typically be completed in 10 minutes or less, future explorations might also consider the utility of developing a short-form. Such an abbreviated version could be implemented in larger care systems (e.g., primary care or hospital settings) to bring greater awareness of BDD symptomatology.

Further, future work with the BDD-SS should also examine symptom prevalence in non-research (e.g., clinical), non-treatment-seeking (e.g., community) and non-clinical (e.g., healthy, subclinical) samples to establish norms and gain a deeper psychometric understanding of the scale. Currently the BDD-SS does not have a cut point to determine treatment response. Collecting BDD-SS data in non-clinical samples of men and women would allow researchers to establish a Clinically Meaningful Change Value; that is, the point on the scale where the participant is more likely to fall into the non-clinical distribution rather than the clinical score distribution. This analysis could enhance diagnostic precision and treatment recommendations when assessments are completed via self-report or otherwise without the involvement of a rater or a clinician specializing in BDD. Longitudinal data with non-treatment-seeking clinical samples would also allow for the examination of test-retest reliability of the BDD-SS. Further research is also needed to better understand the differences and optimal use-cases between rater-administered and self-reported symptom severity.

Highlights.

  • The BDD-SS is a broad self-report measure of BDD symptoms and severity.

  • The BDD-SS demonstrated good psychometric properties in treatment-seeking samples.

  • It was sensitive to change, but less sensitive than rater-administered BDD-YBOCS.

  • The BDD-SS can assess symptom change when rater assessments are not feasible.

Role of funding source:

This report was supported in part by a number of grants from the National Institute of Mental Health awarded to Drs. Phillips and Wilhelm (R01 MH091023; R01 MH091078; R01 MH072917; R01 MH072854) and the David Judah Fund.

Declaration of Interest:

Dr. Wilhelm is a presenter for the Massachusetts General Hospital Psychiatry Academy in educational programs supported through independent medical education grants from pharmaceutical companies; she has received royalties from Elsevier Publications, Guilford Publications, New Harbinger Publications, Springer, and Oxford University Press. Dr. Wilhelm has also received speaking honoraria from various academic institutions and foundations, including the International Obsessive Compulsive Disorder Foundation, Tourette Association of America, and Brattleboro Retreat. In addition, she received payment from the Association for Behavioral and Cognitive Therapies for her role as Associate Editor for the Behavior Therapy journal, as well as from John Wiley & Sons, Inc. for her role as Associate Editor on the journal Depression & Anxiety. Dr. Wilhelm has also received honoraria from One-Mind for her role in PsyberGuide Scientific Advisory Board. Dr. Wilhelm is also on the Scientific Advisory Board for Koa Health. Dr. Wilhelm has received salary support from Novartis and Koa Health. Dr. Greenberg has received salary support from Koa Health and is a presenter for the Massachusetts General Hospital Psychiatry Academy in educational programs supported through independent medical education grants from pharmaceutical companies. In the past year, Dr. Phillips has received book royalties from Oxford University Press, International Creative Management, Inc., American Psychiatric Association Publishing, Inc., and Guilford Publications, and writing royalties from UpToDate/Wolter’s Kluwer. She is on the Advisory Board of Nview, from whom she will receive stock options and expects future payment for scale use. She has received speaking honoraria from academic institutions and professional organizations.

Footnotes

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1

Of note, the absence of endorsement of anabolic steroid use may have been influenced in part by the (largely female) sample, as most individuals with the muscle dysmorphia form of BDD, with which anabolic steroid use is associated, are male.

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