Social Avoidance as a Predictor of Psychosocial Functioning in Body Dysmorphic Disorder: A Prospective Longitudinal Analysis

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.

This is a preview of subscription content, access via your institution.

Fig. 1

Notes

  1. 1.

    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

  1. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: American Psychiatric Association.

    Google Scholar 

  2. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: American Psychiatric Association.

    Book  Google Scholar 

  3. 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.

    Article  PubMed  Google Scholar 

  4. 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.

    Article  PubMed  Google Scholar 

  5. 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.

    Article  PubMed  Google Scholar 

  6. 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.

    CAS  Article  PubMed  Google Scholar 

  7. 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.

    CAS  Article  PubMed  Google Scholar 

  8. 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.

    Article  PubMed  Google Scholar 

  9. Diggle, P., Liang, K., & Zeger, S. L. (1994). Analysis of longitudinal data. Oxford: Clarendon Press.

    Google Scholar 

  10. 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.

    Google Scholar 

  11. 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.

    Google Scholar 

  12. 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.

    Article  PubMed  PubMed Central  Google Scholar 

  13. 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.

    Article  PubMed  Google Scholar 

  14. 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.

    Article  PubMed  PubMed Central  Google Scholar 

  15. 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.

    Article  PubMed  Google Scholar 

  16. 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.

    CAS  Article  PubMed  Google Scholar 

  17. 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

    Google Scholar 

  18. 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.

    Article  PubMed  Google Scholar 

  19. 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.

    Article  PubMed  PubMed Central  Google Scholar 

  20. 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.

    Article  PubMed  Google Scholar 

  21. 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.

    CAS  Article  PubMed  Google Scholar 

  22. 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.

    CAS  PubMed  Google Scholar 

  23. 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.

    Article  Google Scholar 

  24. 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.

    Article  PubMed  PubMed Central  Google Scholar 

  25. 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.

    Article  PubMed  PubMed Central  Google Scholar 

  26. 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

    Google Scholar 

  27. 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.

    Google Scholar 

  28. 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.

    Article  PubMed  PubMed Central  Google Scholar 

  29. 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.

    Article  PubMed  PubMed Central  Google Scholar 

  30. 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

    Google Scholar 

  31. Singer, J. D., & Willett, J. B. (2003). Applied longitudinal data analysis: Modeling change and event occurrence. New York: Oxford University Press.

    Book  Google Scholar 

  32. 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

    Google Scholar 

  33. 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.

    Article  PubMed  Google Scholar 

  34. 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.

    CAS  Article  PubMed  Google Scholar 

  35. 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.

    Article  PubMed  Google Scholar 

  36. 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.

    Article  PubMed  PubMed Central  Google Scholar 

  37. Wilhelm, S., Phillips, K. A., & Steketee, G. (2013). Cognitive-behavioral therapy for body dysmorphic disorder: A treatment manual. New York: Guilford Press.

    Google Scholar 

Download references

Funding

This study was supported by the National Institutes of Mental Health (R01 MH6024).

Author information

Affiliations

Authors

Corresponding author

Correspondence to Timothy R. Ritzert.

Ethics declarations

Conflict of interest

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.

Ethical Approval

All procedures involving human participants were in accordance with the ethical standards of the institutional review board (removed for blind review) and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed Consent

Informed consent was obtained from all individual participants included in the study. Parents/guardians provided informed consent when applicable.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

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

Download citation

Keywords

  • Body dysmorphic disorder
  • Psychosocial functioning
  • Social anxiety
  • Social avoidance
  • Relationships