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BDD is characterised by an intense, impairing and distressing preoccupation with perceived flaws in one’s own physical appearance that appears non-existent or slight to others, and is often accompanied with participation in time-consuming, repetitive behaviours or mental acts in response to appearance concerns (American Psychiatric Association, 2013; World Health Organization, 2018). The disorder usually emerges during adolescence (Bjornsson et al., 2013) and is estimated to effect 1.7-3.6% of young people (Möllmann et al., 2017; Schneider et al., 2016). BDD is associated with reduced quality of life, poor social, educational and family functioning, comorbid psychopathology, and concerningly high rates of suicidality (e.g. Angelakis et al., 2016; Didie et al 2008; Krebs et al., 2020; Mataix-Cols et al., 2015; Phillips et al., 2005). NICE (2005) guidelines recommend cognitive behavioural therapy (CBT), incorporating exposure with response prevention (E/RP), and serotonin reuptake inhibitors in the treatment of BDD (Krebs et al., 2017a). Although a Randomized Controlled Trial (RCT) of CBT for BDD in adolescents found CBT to be efficacious in reducing BDD symptoms (Mataix-Cols et al., 2015), only 50% of adolescents were considered treatment responders at one year follow-up (Krebs et al., 2017b). Consequently, it appears that distressing symptoms of BDD can persist, and therefore improvements in existing CBT interventions are required. Researchers have started to explore factors predicting treatment response in BDD in order to further understand the development and maintenance of the disorder (e.g. Harrison et al., 2016; Flygare et al., 2020; Greenberg et al., 2019; Krebs et al., 2017b; Phillips et al., 2021). Such research has focussed upon insight and depression as potential predictors, and findings indicating the significance of predictors have been inconsistent across studies. In a systematic review and meta-analysis of RCTs of CBT for BDD, Harrison et al. (2016) did not find any significant predictors of treatment outcome. Consequently, predictors of treatment response, and therefore mechanisms maintaining the disorder, remain unclear. BDD is classified under the Obsessive-Compulsive and Related Disorders chapter in diagnostic manuals due to the phenomenological similarities and high rates of comorbidity between BDD and OCD (Krebs et al., 2017a). Core clinical features of both disorders are the intrusive, anxiety-inducing obsessions and ritualistic behaviours engaged in compulsively to reduce distress or anxiety. Given the diagnostic overlap between OCD and BDD, exploring factors evidenced to maintain symptoms in OCD is an interesting avenue for BDD research. One factor extensively researched in the maintenance of OCD is family accommodation (FA), which refers to the involvement and participation of family members in an individual’s rituals, such as providing objects, following desired routines, assisting avoidance, and providing reassurance. Accommodation among families of children with OCD is extremely common (e.g. Futh et al., 2012; Kagan et al., 2017; Lebowtiz & Bloch 2012; Lebowitz et al., 2014; Merlo et al., 2009; Monzani et al., 2020; Peris et al., 2008; Pontillo et al., 2020; Wu et al., 2019). Although FA is often well intended because parents are seeking to reduce their child’s distress, there are unintentional adverse short- and long-term consequences which maintain distress and OCD symptoms. For example, high levels of FA of paediatric OCD have been associated with higher OCD symptom severity (Kagan et al., 2017; Lebowtiz & Bloch 2012; Lebowtiz et al., 2014; Merlo et al., 2009; Monzani et al., 2020; Storch et al., 2007; Strauss et al., 2014; Wu et al., 2016; Wu et al., 2019), increased functional impairment (Pontillo et al., 2020; Wu et al., 2019), greater child internalizing and externalizing symptoms (Caporino et al., 2012; Monzani et al., 2020; Storch et al., 2007), and increased parent psychopathology (anxiety/depression: Caporini et al., 2012; Flessner et al., 2011; Futh et al., 2012; Monzani et al., 2020; Peris et al., 2008; Pontillo et al., 2020). Furthermore, research has found an association between FA and OCD treatment outcomes (Francazio et al., 2016; Kagan et al., 2017; Lebowtiz & Bloch 2012; Merlo et al., 2009; et al., Monzani 2020), in which higher levels of FA of paediatric OCD at pre-treatment were found to predict worse treatment outcomes. Additionally, decreases in FA have been associated with significant improvements in OCD symptom severity over treatment. Consequently, FA is important to address in interventions for OCD to support positive treatment outcomes. A further association of FA important to consider is parental psychopathology. Parental anxiety has been shown to significantly predict FA of child OCD symptoms (Flessner et al., 2011), and it has been suggested that engaging in FA can activate parental distress (Peris et al., 2008; Pontillo et al., 2020). Therefore, researchers have hypothesised that a parent’s own emotional response may need to be targeted in the treatment of the child’s OCD symptoms because parents who present with their own psychopathology may find it difficult to tolerate their own and child’s distress during E/RP (Caporino et al., 2012; Flessner et al., 2011; Peris et al., 2008). However, there is currently a lack of research investigating the associations between parental psychopathology and treatment outcomes for child OCD. Given the overlap between paediatric OCD and BDD, it has been hypothesised that families may accommodate BDD symptoms (Murphy & Flessner, 2015). There has only been one study thus far exploring the presence and form of FA in paediatric BDD. In a qualitative study, Jassi et al. (2020) interviewed CYP with BDD, parents of CYP with BDD, and clinicians working in a specialist BDD clinic. All participants reported to have experienced FA in BDD, and FA was used by families to minimise child distress and reduce risk to self. FA behaviours were mostly similar to those observed in OCD. Furthermore, all parents expressed that FA negatively impacted upon their own emotional wellbeing. This qualitative study highlights the importance of understanding FA in young people with BDD. Of note, there have not been any quantitative studies of FA in paediatric BDD symptoms, and therefore the prevalence, demographic and clinical correlates, and implications for treatment remain unclear. This project seeks to contribute to the understanding of the underlying mechanisms maintaining symptoms of paediatric BDD by undertaking the first quantitative investigation of maternal accommodation of BDD symptoms in a sample of children and young people (CYP) accessing CBT for BDD. This is a naturalistic study of a clinical cohort using a database analysis. The study will utilise existing anonymised data that has been collected as part of routine clinical practice, in the National and Specialist OCD, BDD and Related Disorders Clinic for CYP at The Maudsley Hospital. CYP will be included in pre-post treatment analyses if they received CBT. Mother-reported data is being utilised because within the dataset mothers are the primary caregiver for 95% of CYP who attended the clinic. |
