Individuals with body dysmorphic disorder (BDD) experience elevated social avoidance, both as a consequence and independent of BDD concerns. To explore how social avoidance relates to the long-term course of functioning for people with BDD, this prospective longitudinal study evaluated the hypothesis that initial social avoidance would predict changes in psychosocial functioning over 3 years, such that greater initial social avoidance would predict worsening functioning. At intake, individuals with BDD (N = 200) completed measures of social avoidance independent of BDD, social avoidance due to BDD or any other source, overall psychosocial functioning, and psychosocial functioning in specific domains. Overall and specific functioning was prospectively evaluated at three subsequent yearly follow-up assessments. Mixed model analyses evaluated the relation between baseline social avoidance and changes in functioning. Results provided mixed support for hypotheses, indicating that higher baseline social avoidance independent of BDD predicted worsening functioning in two of the four overall functioning indices and in both specific domains—interpersonal relationship quality and work/academic/household functioning. Higher global social avoidance (due to BDD or any other source) predicted poorer overall functioning for two of the four global functioning indices but did not predict functioning in either specific domain. Social avoidance, both related and unrelated to body image, might play an important role in the trajectory of psychosocial functioning for people with BDD.
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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.
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This study was supported by the National Institutes of Mental Health (R01 MH6024).
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.
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 was obtained from all individual participants included in the study. Parents/guardians provided informed consent when applicable.
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Ritzert, T.R., Brodt, M., Kelly, M.M. et al. Social Avoidance as a Predictor of Psychosocial Functioning in Body Dysmorphic Disorder: A Prospective Longitudinal Analysis. Cogn Ther Res 44, 557–566 (2020). https://doi.org/10.1007/s10608-019-10069-0
- Body dysmorphic disorder
- Psychosocial functioning
- Social anxiety
- Social avoidance