The life table analysis in (allowing for censoring) shows the estimated partial remission rates and the partial or full remission rates achieved at one or more 6-month assessment points (as assessed by the BDD-PSR) during the 4-year follow-up period. For example, by 1 year, 24.7% of subjects had achieved full remission and 57.8% had achieved partial or full remission at the 6-month and/or 12-month assessment point. After 4 years, 58.2% of subjects had achieved full remission, and 83.8% had achieved partial or full remission, in at least one assessment point. Of those subjects who achieved partial or full remission at one or more assessment points, and who had at least one 6-month assessment subsequent to attaining remission, 71.4% (n = 25) remained in remission (either partial or full) at all subsequent 6-month follow-up assessments (ie, 28.6% subsequently relapsed at one or more 6-month assessment points). Twenty-nine (30.5%) patients discontinued treatment during the follow-up period; excluding the 7 patients who discontinued treatment because the first author moved her practice, the treatment dropout rate was 23.2% (n = 22). Patients dropped out of treatment for the following reasons: lost contact/unknown (n = 13), the patient moved (n = 2), poor insight and belief that treatment was not necessary (n = 2), financial (n = 2), the patient was doing well with no treatment (n = 1), the patient wanted a different provider (n = 1), and excessive driving distance (n = 1).
Fig. 1 Time to full or partial remission of BDD. The life table analysis above (allowing for censoring) shows the estimated partial remission rates and the partial or full remission rates achieved at one or more 6-month assessment points (as assessed by the (more ...)
shows ratings at baseline and the most recent clinic visit. Baseline BDD-PSR and BDD-YBOCS scores indicate that at baseline most subjects met full criteria for BDD, which was moderately severe. Body dysmorphic disorder symptom severity significantly decreased, as assessed by the BDD-PSR, BDD-YBOCS, and BDD-CGI severity scale. The mean BDD-PSR score decreased from 5.7 ± 1.0 at baseline to 4.1 ± 1.5 at the last assessment (t = 9.9, df = 89, P < .001). Patients who dropped out of treatment were significantly less ill at the last assessment than those who remained in treatment (end point BDD-PSR score of 3.7 for dropouts vs 4.4 for nondropouts; t = 2.04, df = 88, P = .045). On the BDD-CGI improvement scale, 59.1% of patients were improved at the most recent visit. (This CGI result is roughly comparable to the survival data because, as noted above, of the 83.8% of subjects who achieved partial or full remission at some point during follow-up, 28.6% subsequently relapsed, leaving 59.8% in remission at all remaining follow-up assessments.) Overall symptom severity and level of functioning as assessed by the GAF and SOFAS also significantly improved.
Symptom severity and functional impairment at baseline and the most recent assessment for patients with BDD
Regarding predictors of outcome, baseline BDD severity (BDD-YBOCS score), as hypothesized, was significantly positively correlated with BDD severity (BDD-PSR score) at the most recent assessment (r = 0.34, P = .003). Current major depression (r = 0.33, P = .002) and current social phobia (r = 0.24, P = .03) at baseline were also significantly correlated with BDD severity at the most recent assessment. However, there was no significant association between end point BDD severity and the presence of a personality disorder (r = 0.22, P = .19) or OCD (r = 0.21, P = .06) at baseline, baseline delusionality (r = −0.11, P = .44), or BDD duration (r = −0.04, P = .73).
Of those subjects whose BDD improved (on the BDD-CGI) between baseline and the most recent assessment, 13 of 15 with major depression at baseline also had improvement in depression, and 6 of 6 with OCD at baseline also had improvement in OCD. Conversely, of subjects with current OCD at baseline, 6 of 10 had improvement in OCD, all 6 of whom also had improvement in BDD. Of subjects with major depression at baseline, 18 (54.5%) of 33 had improvement in depression, 13 (76.5%) of whom also had improvement in BDD.
During the follow-up period, all subjects received psychotropic medication, with 2.8 ± 2.3 (range, 1–13) medication trials and 17.2 ± 24.2 (range, 2–164) medication visits per subject; on average, medication visits occurred every 5 weeks. All subjects received an SRI, 36.4% (n = 32) received buspirone, 26.1% (n = 23) an antipsychotic, 12.5% (n = 11) a benzodiazepine, 9.1% (n = 8) a non-SRI antidepressant, 8.0% (n = 7) a mood stabilizer, and 5.7% (n = 5) a stimulant. The mean maximum SRI doses were: fluoxetine, 68.3 ± 26.7 mg/d (range, 20–140 mg/d; n = 72 trials); clomipramine, 165.5 ± 76.0 mg/d (range, 50–250 mg/d; n = 21 trials); fluvoxamine, 229.4 ± 93.2 mg/d (range, 25–350 mg/d; n = 17 trials); sertraline, 164.7 ± 76.1 mg/d (range, 25–300 mg/d; n = 17 trials); and paroxetine, 41.5 ± 14.6 mg/d (range, 20–70; n = 13 trials). There was a trend for subjects meeting full BDD criteria at the most recent assessment to have received more medications than those who did not meet full criteria (3.5 ± 2.3 vs 2.5 ± 2.5, t = −1.8, df = 81, P = .08). A total of 48.6% (n = 36) of subjects received therapy: 34.3% (n = 24) received supportive or insight-oriented psychotherapy, and 21.7% (n = 20) received CBT. The mean number of therapy sessions was 20.9 ± 23.8 (range, 3–88). Subjects who met full BDD criteria at the most recent assessment were as likely to have received CBT as those who did not meet full criteria (57.9% [n = 11] vs 42.1% [n = 8], χ2 = .47, df = 1, P = .47); this was also the case for non-CBT psychotherapy (50.0% [n = 11] for both groups).