Body dysmorphic disorder (BDD) is a psychiatric disorder consisting of distressing or impairing preoccupations with nonexistent or slight defects in appearance, combined with repetitive behaviors performed in response to appearance concerns (e.g., mirror checking, excessive grooming). BDD is often associated with significant functional impairment and poor quality of life and increased risk for attempted and completed suicide.
Serotonin reuptake inhibitors (SRIs) are the first-line pharmacotherapy for body dysmorphic disorder (BDD); however, a relatively large proportion of patients (30%-40%) are non-responders. Our ability to identify predictors of response to SRIs would ultimately help to develop more effective treatment algorithms. In a recent study, Angela Fang, PhD in collaboration with Sabine Wilhem, PhD examined personality dimensions and traits in a group of adults with BDD and determined whether these variables could be used to predict response to treatment with the SRI escitalopram.
This study derives from a secondary analysis of data from a pharmacotherapy relapse prevention trial of escitalopram in adults with BDD (Phillips KA et al, 2016). A total of 65 participants with BDD completed the Revised NEO Personality Inventory (NEO PI-R) before receiving open-label treatment with escitalopram, and 42 participants completed the NEO PI-R after treatment.
At baseline, the majority of participants (n = 41, 64.1%) met diagnostic criteria for at least one personality disorder. The most common personality disorder was avoidant personality disorder (n = 31, 48.4%), followed by depressive personality disorder (n = 13, 20.3%) and paranoid personality disorder (n = 11, 17.2%). Participants with a higher number of personality disorder diagnoses at baseline experienced greater BDD symptom severity.
At baseline, adults with BDD displayed higher levels of neuroticism (a tendency to experience negative affect – fear, sadness, embarrassment, anger, guilt, and disgust) and lower levels of extraversion and conscientiousness than a normed reference group. Higher levels of neuroticism at baseline predicted nonresponse to escitalopram treatment, even after controlling for baseline depression severity. Changes in neuroticism were not associated with treatment response; in other words, patients who experienced a decrease in neuroticism during the course of treatment did not necessarily experience a decrease in BDD symptoms.
What are the clinical implications? Would we use personality testing in a clinical context? The fact that neuroticism predicts treatment response but does not change during treatment points to the fact that predictors and mechanisms may not always be the same thing. Predictors may reflect an important capacity necessary for treatment success but may not reflect any of the multiple processes by which symptoms improve. At this point, we are not at the point where we can use personality testing to guide treatment recommendations; however, the goal is to use this sort of person-level information, including personality dimensions, to include in prediction models that can inform and improve treatment recommendations.
Read More:
Fang A, Porth R, Phillips KA, Wilhelm S. Personality as a Predictor of Treatment Response to Escitalopram in Adults With Body Dysmorphic Disorder. J Psychiatr Pract. 2019 Sep;25(5):347-357. Free Article.
Phillips KA, Keshaviah A, Dougherty DD, Stout RL, Menard W, Wilhelm S. Pharmacotherapy Relapse Prevention in Body Dysmorphic Disorder: A Double-Blind, Placebo-Controlled Trial. Am J Psychiatry. 2016 Sep 1;173(9):887-95. Free Article.
Angela Fang, PhD completed this work as part of her research in the OCD and Related Disorders Program at MGH. She is currently an Assistant Professor at the University of Washington. Her current research focuses on understanding the social cognitive biases underlying anxiety and obsessive-compulsive related disorders in order to inform mechanisms to target in treatment.
Publications: Harvard Catalyst Pubmed Research Gate
Sabine Wilhelm, PhD is the Chief of Psychology and the Director of the Obsessive-Compulsive and Related Disorders Program at Massachusetts General Hospital. She is a Professor of Psychology (Psychiatry) at Harvard Medical School. Dr. Wilhelm is recognized as a leading researcher in OCD and related disorders, and has published over 270 articles and reviews on cognitive functioning, prevalence and treatment outcomes of these disorders. She is especially interested in the development and testing of new technologies to treat illness and improve quality of life.
Publications: Harvard Catalyst Pubmed Research Gate
