Protecting our Most Vulnerable: The Suicidality Crisis in Black Children

A Call to Action

In April 2019 the Congressional Black Caucus (CBC) gathered to confront the pressing concern over Black children who were dying by suicide at an unprecedented rate in America.[1] After its meeting, the caucus determined that it was their responsibility to identify this crisis as a Black health emergency, and subsequently built a coalition that has since spent the past four years working towards solutions. 

The suicidality issue amongst young Black Americans initially came as a surprise to the CBC and other researchers within the mental health sector. Historically, the suicide rate within the overall Black community has been lower than that of the national average, particularly in comparison to White Americans.[2] Even between 2021 and 2022 the Center for Disease Control (CDC) recorded 48,183 suicides within the United States, with only 7% of the group identifying as Black American.[3] However, a closer look at suicide trends began to indicate a growing rate in Black children. Price & Khubchandani (2020) analyzed data between 2001 and 2017, discovering that the rate of suicides in young Black men and women increased by 60% and 182%, respectively.[4] They also found that suicide was the second highest cause of death for Black adolescents.[5]

Research conducted by the CDC in 2021 also drew similar conclusions: Black male children aged five to 11 are at risk to the point where they are twice as likely to die by suicide over their White counterparts.[6] Similarly, the Journal of the American Academy of Child & Adolescent Psychiatry analyzed data between 2003 to 2017 and found Black girls between the ages of 15 to 17 had the largest percentage in suicides of all race and gender-based demographics.[7]

Understanding the “Why” behind Black Youth Suicidality

With Black children dying by suicide at such an unprecedented rate, the CBC began to focus on the causes, supposing that each cause would later have an accompanying solution it could implement in order to address this crisis. While all children are vulnerable to bullying, issues with self-identity, and hormonal changes that can cause depression and suicidal ideations, the CBC found that the compounding impacts of trauma, cultural stigmas, and socioeconomic barriers are uniquely faced by Black children. Mathew et al. (2020) found that of children who attempt suicide, having a hostile family environment and perceiving a lack of care from family members within a household have been discovered as contributing factors to suicidal behavior among adolescents and young adults.[8] Black children have the highest likelihood of witnessing home violence, experiencing communal stigmas in response to mental crisis, and enduring distressing racism and discrimination, all of which have the potential to exacerbate their likelihood of not wanting to live.[9,10] In the face of these compounding factors, young Black men often feel a sense of hopeless that is further aggravated by the racism and discrimination they face within society.[11] Black girls also combat the complex intersectionality of race and gender-based discrimination, encountering racism while also having a higher likelihood than their male counterparts of being sexually assaulted. With race and gender-based pressures mounting, young Black women have a singular struggle in overcoming sexual harassment, misogyny, and racism - all of which make them more vulnerable to depression and suicidal ideations.[12]

The Necessity of Support

For all children, familial and community support play pivotal roles in mental health outcomes. A strong support system can serve as a protective factor against suicide, especially for Black children where familial support and communalism are heavily integrated in Black culture.[13] In the absence of a strong support system, children often feel isolated and have a higher likelihood of experiencing depression and/or suicidal ideation.[14] In a 2020 report conducted by the U.S. Department of Health and Human Services, researchers concluded that Black children had a high likelihood of experiencing crisis in the two weeks prior to their death by suicide.[15] Further, nearly 40% of Black youth had a crisis or dispute with a family member, romantic partner, or friend before their death by suicide; 30% of this group had an argument within 24 hours of their death.[16] Within the Black community, providing accessible resources to navigate relationship issues and familial trauma can provide useful support to save a child’s life.

The Trouble in Exhibiting Mental Health Issues

For all children suffering from depression and mental health struggles, early detection and timely treatment are essential to mitigating their symptoms. However, Black children are the most likely to be suspended, expelled, or labeled with “behavioral issues” when they are actually displaying mental health issues. A 2015 study conducted by Okonofua & Eberhart concluded that educators often perceive black students’ behaviors as more problematic and more punishable than those of their White counterparts.[17] This study not only exhibits racial disparities in disciplinary action, but it also points to the isolation Black children face in the midst of a crisis. 

The Lack of Mental Health Intervention

While intervention is key to preventing a child from getting to the point where they attempt suicide, mental health issues remain underdiagnosed and stigmatized within the Black community. In its 2020 report to Congress, the U.S. Department of Health and Human Services identified this contradiction: despite dying by suicide at a faster rate than any other racial/ethnic group, Black youth had lower reported rates of known mental health problems and documented histories of suicidal thoughts or plans. However, the lack of reported rates of mental health issues is not equivalent to these problems being nonexistent for Black children. On the contrary, the low rates of recorded mental health disorders that stand in contrast to the high rates of past suicide attempts suggest that Black youth are still experiencing depression, but they have limited access to mental healthcare and proper treatments. Not only do Black children face barriers to attaining effective mental health resources because of the high cost of therapy, but the American Psychological Association (APA) note the United States has a shortage of culturally-competent therapists across the country.[18] With over 88% of mental health providers identifying as white, young Black children continue to have more difficulty finding therapists that look like them and with whom they can identify.[19]

Mental Health Stigma Within the Black Community

Within the Black community, mental health conditions are not only misunderstood, but many Black adults view mental health conditions as a weakness.[20] As a result, people within this community may face embarrassment about their mental health condition and worry that they may be ostracized if they share how they are struggling with friends or family.[21] This perspective is not only damaging to Black adults, who will often mask their mental health disorders, but also to Black children who are the most vulnerable and often also the most susceptible to being silenced in a time of distress.[22] 

Further, another obstacle for this cohort is that many Black Americans turn to spirituality and a faith-based community rather than seeking a medical diagnosis.[23] While spirituality is a proven source of resiliency for many ethnic minorities and can provide healthy outlets and reduce isolation, it is not always effective or effective enough in crisis.[24] In contrast, children should be encouraged to seek out multiple treatment avenues to ensure the highest chance of recovery from mental illness.

Solutions to the Suicide Crisis 

The CBC concluded that addressing the issue of youth suicide within the Black community demanded a comprehensive approach that continues to consider the complex intersection of mental health, cultural, and socioeconomic factors. They note the following factors are essential to halting the trend of Black children ending their lives:

1. Schools stand at the forefront of community-based care and they can close the gap in mental-health access by offering all students access to affirming environments and well-trained professionals. Unlike mental health care provided by hospitals, mental health professionals in schools have the ability to provide resources and assistance to students without the barriers of insurance and financial security. Schools within a child’s community also have the potential to help a child overcome their mental health challenges with culturally-relevant care.

2. Expanding access to underprivileged communities has the potential to give Black children access to treatment that would otherwise be unavailable. As the American Psychological Association (APA) asserts, telehealth with expanded coverage via the assistance of insurance companies is an equity-based solution that may allow Black children to get the treatment they are seeking.[25]

3. Black researchers must also be given adequate funding and support in order to narrow the knowledge gap that leaves Black-specific illnesses underreported. Research topics proposed by Black scientists are less likely to be funded, leaving profound gaps in the level of understanding that is required to protect Black youths from the unique challenges they face.

In 2019, Congresswomen Coleman and Napolitano led the CBC in proposing the “Pursuing Equity in Mental Health Act.” The act has successfully passed the House of Representatives, and once it is officially enacted it will provide $750 million annually between fiscal years 2024 to 2029 for the National Institute on Minority Health and Health Disparities.[26] The future act will also authorize $150 million dollars to the National Institutes of Health (NIH) to build mental health facilities within Black communities, support clinical research, and work to end racial/ethnic disparities in healthcare.[27]

Ensuring Children Have Hope in their Future

Ultimately, Black children face the unique challenge of navigating their lives at the intersection of race, gender, and sexual orientation all while carrying the basic challenge of simply “being kids”. With societal pressures and feelings of isolation becoming prevalent within the current generation, it is essential for the adults within their lives to make sure that they are protected and supported. Children are a vulnerable population who are not fully capable of self-advocacy, and for this reason the rising suicide rates among Black children necessitates collective action. By addressing the mental health stigma within the Black community, systemic inequalities and cultural factors, American society will build a mental healthcare system where, regardless of their background, all children feel supported and capable of overcoming trauma.

If you or someone you know is struggling with depression, hopelessness and/or suicidal thoughts, please call 911, 988, or go to the closest emergency room. Individuals seeking non-crisis support can also reach out to a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) for guidance and additional resources. 

Contributed by: Kate Campbell

Editor: Jennifer (Ghahari) Smith, Ph.D.

References

1 Coleman, B.W. (2023). Emergency Task Force on Black Youth Suicide and Mental Health.https://watsoncoleman.house.gov/suicidetaskforce/

2 Kung, K. C., Liu, X., & Juon, H. S. (1998). Risk factors for suicide in Caucasians and in African-Americans: a matched case-control study. Social psychiatry and psychiatric epidemiology, 33(4), 155–161. https://doi.org/10.1007/s001270050038

3 Langston, L. & Truman, J.L. (2014). Socio-Emotional Impact of Violence. Bureau of Justice Statistics. https://bjs.ojp.gov/library/publications/socio-emotional-impact-violent-crime

4 Price, J. H., & Khubchandani, J. (2019). The Changing Characteristics of African-American Adolescent Suicides, 2001-2017. Journal of community health, 44(4), 756–763. https://doi.org/10.1007/s10900-019-00678-x

5 Ibid

6 Meza, J.L., Patel, K., Bath, E. (2022). Black Youth Suicide Crisis: Prevalence Rates, Review of Risk and Protective Factors, and Current Evidence-Based Practices. Focus: The Journal of Lifelong Learning in Psychiatry, 20(2), 197-203. https://doi.org/10.1176/appi.focus.20210034

7 Sheftall, A. H., Vakil, F., Ruch, D. A., Boyd, R. C., Lindsey, M. A., & Bridge, J. A. (2022). Black Youth Suicide: Investigation of Current Trends and Precipitating Circumstances. Journal of the American Academy of Child and Adolescent Psychiatry, 61(5), 662–675. https://doi.org/10.1016/j.jaac.2021.08.021

8 Mathew, A., Saradamma, R., Krishnapillai, V., & Muthubeevi, S. B. (2021). Exploring the Family factors associated with Suicide Attempts among Adolescents and Young Adults: A Qualitative Study. Indian journal of psychological medicine, 43(2), 113–118. https://doi.org/10.1177/0253717620957113

9 Chopra, S. (2022, September 9). Black girls are experiencing record rates of self-injury and death by suicide. https://youthtoday.org/2022/09/black-girls-are-experiencing-record-rates-of-self-injury-and-death-by-suicide/

10 Langston, L. & Truman J.L. (2014)

11 Meza, J.L., Patel, K., Bath, E. (2022)

12 American Academy on Child and Adolescent Psychiatry. (2022) AACAP Policy Statement on Increased Suicide Among Black Youth in the US. https://www.aacap.org/aacap/Policy_Statements/2022/AACAP_Policy_Statement_Increased_Suicide_Among_Black_Youth_US.aspx

13 Langston, L. & Truman, J.L. (2014)

14 Bethune, S. (2022). Increased need for mental health care strains capacity. American Psychological Association (APA). https://www.apa.org/news/press/releases/2022/11/mental-health-care-strains

15 Okonofua, J. A., & Eberhardt, J. L. (2015). Two Strikes: Race and the Disciplining of Young Students. Psychological Science, 26(5), 617–624. https://doi.org/10.1177/0956797615570365

16 Okoya, Wenimo. (2022, March 30). The fight for Black Lives needs to happen in schools. The Hechinger Report. https://hechingerreport.org/opinion-the-fight-for-black-lives-needs-to-happen-in-schools/

17 Okonofua, J.A., & Eberhardt, J.L. (2015)

18 Ward, E. C., Wiltshire, J. C., Detry, M. A., & Brown, R. L. (2013). African American men and women's attitude toward mental illness, perceptions of stigma, and preferred coping behaviors. Nursing research, 62(3), 185–194. https://doi.org/10.1097/NNR.0b013e31827bf533

19 Meza, J.L., Patel, K., Bath, E. (2022)

20 Ibid.

21 Okonofua, J. A., & Eberhardt, J. L. (2015) Nguyen A. W. (2020). 

22 Bethune (2022)

23 Religion and Mental Health in Racial and Ethnic Minority Populations: A Review of the Literature. Innovation in aging, 4(5), https://doi.org/10.1093/geroni/igaa035

24 Ibid.

25 The Mental Health Liaison Group.(2023).  MHLG Letter of Support - Pursuing Equity in Mental Health Act 118th Congress. https://adaa.org/MHLG098402

26 Ibid.

27 Ibid.

Addressing Mental Health Amongst First Responders: Sometimes Superheroes Need Saving, Too

Hidden Anguish

First responders play a vital and commendable role in society as they display exceptional bravery to save the lives of others, often at the risk of their own. Many first responders encounter unimaginable tragedy and horror on a daily basis, and then are expected to go home and attend to their loved ones. However, separating work from personal life may not be so easy for these individuals as the impact that traumatic events can have on one’s mental health is often left unacknowledged. Frequent exposure to death and tragedy undoubtedly affects one’s psychological state of well-being, including post-traumatic stress disorder (PTSD), substance abuse, depression and especially suicidal ideations. However, along with the societal expectation of first responders to be brave and strong, comes the suppression of such mental health problems and lack of proper psychiatric treatment.[1] 

Risk factors & Causes 

In comparison to the general population, first responders such as law enforcement officers (LEO), emergency medical technicians (EMT), and firefighters are at a greater risk of suicide ideation and suicide. Stanley et. al. (2016) conducted a systematic review of 63 quantitative studies examining the suicidal thoughts, behaviors, and fatalities of first responders, and found them to be at a significantly higher risk than general population samples.[2] Bond & Anestis (2021) conducted a study which showed that 23-25% of LEOs and 46.8% of firefighters experience suicidal ideations, and 10.4% of EMTs report severe lifetime suicidal ideation.[3] Frequent and severe traumatic experiences also lead to a higher risk of PTSD. Approximately 32% of LEOs, 22% of EMTs and 32% of firefighters experience PTSD. In comparison to the general civilian population, out of whom only 7-12% experience PTSD, these rates are concerningly high. There are also various risk factors amongst first responders that can contribute to their increased risk of developing PTSD, including:[4]

• Family history of psychiatric disorders

• Childhood trauma (abuse/adversity)

• Intelligence level

• Education

• Early conduct problems

Proper sleep hygiene (due to long and demanding shift schedules) also plays a role in the increased rates of disorders such as PTSD, depression, and anxiety. A longitudinal study conducted by Feldman et al. (2021) included 135 emergency medical service providers and recorded changes in symptoms of various psychological disorders over the course of 3 months. Their findings revealed that the increase in symptoms of PTSD, depression, and anxiety were all correlated with a poor sleep pattern and lower social support.[5] Erratic sleep patterns are especially problematic given that they compromise inflammatory and physiological stress responses.[6]

Acute stress disorder (ASD) is another common psychiatric disorder among first responders who experience frequent and high-impact stressors. A few pertinent symptoms of this disorder include:[7]

• Hyperarousal

• Negative mood

• Anger/irritability

• Dissociation

• Avoidance

• Numbing

• Nightmares

• Intrusive thoughts

ASD is developed once an acute stress response leads to more serious impairments after exposure to a traumatic stress with documented biological or psychological sequelae. Within 3 days of the traumatic event, multiple symptoms within five diagnostic categories will appear. ASD is signified by persistent symptoms well beyond the time frame of an acute stress reaction, which is more common and normal for anyone who experiences a traumatic event. While first responders who are acutely impacted by a trauma may develop ASD, developing ASD puts them at a greater risk for subsequently developing PTSD.[8]

The Three-Step Theory 

Not only do first responders experience greater rates of suicidal ideations, but they are also more likely to actually perform suicidal attempts.[9] Ideation-to-action is outlined by the Three-Step Theory (3ST), which states that there are three subcategories of capability that can shift an individual from suicidal thoughts to actual suicidal actions. These subcategories include:[10]

1. Practical - Broader knowledge of lethal weapons/drugs, and potentially even better access to them. The means of suicidal means are more readily obtainable. 

2. Dispositional - Innate tolerance to death and pain. 

3. Acquired - Learned desensitization and tolerance to death and pain. Having encountered numerous tragic events has built a sense of fearlessness in many first responders.

Suffering in Silence

Since a large majority of first responder suicides go unreported by mainstream media, there is an ongoing lack of knowledge/awareness of the general public to the degree that it occurs.  In addition, barriers exist that prevent first responders from accessing the proper psychiatric care they need when experiencing depression or suicidal ideations. Such barriers include shame and stigma surrounding mental health issues within their professions, as the concept of bravery and courage is heavily instilled upon them during training and work. Moreover, first responders and their families often fail to have open discussions about mental health, which unfortunately fuels the lack of awareness on the issue of first responder suicide.[11] 

Even when a first responder recognizes they are in crisis, several factors often prevent them from seeking adequate help: lack of knowledge on where/how to seek help, fear of confidentiality breach, belief that they cannot show weakness, lack of access and availability to therapy, family burden, pride and denial.[12] Destigmatizing mental health issues and spreading awareness is the first crucial step to ensuring that first responders are able to comfortably and willingly ask for help.[13] First responders should also be informed about mental health disorders and how to facilitate help-seeking.[14]

First responders are often expected to prevent their traumatic experiences from interfering with their professional and personal lives. The culture of first responders may prevent them from seeking actual mental health interventions, due to stigma and self-image. However, doing so often leads to unhealthy coping mechanisms such as substance abuse and high-risk behavior as an outlet for their stressors. Some also practice avoidance, leading to absenteeism in work and home, causing tension with their personal relationships. Conflict may even arise between colleagues, as high-stress environments and internal stressors combine together to create overall tension in the workplace. Therefore, psychoeducation to reduce stigma and subcultural barriers could help encourage first responders to seek treatment. This would eventually remediate their own psychological health and mend other impacted professional and personal relationships in their lives.[15] 

Building Resilience 

High resilience has been shown to be associated with lower symptomology of PTSD, depression, and alcohol abuse in active first responders. Therefore, resilience screening can help to protect the long-term mental health of first responders. High resilience indicates the ability to better tolerate problems, illness, failure, pressure, and feelings of pain.

These adaptive qualities of resilience can be developed in first responders via targeted interventions, including cognitive behavioral therapy (CBT) and mindfulness training programs. These two methods have been proven effective in increasing adaptive resilience amongst health professionals, factory workers, civil servants, and even breast-cancer patients. Employing resilience screening as a first responder begins work, one can identify which workers can most benefit from these targeted interventions to increase resilience, thus decreasing their chances of developing debilitating psychological disorders.[16] 

Thompson and Drew (2020) developed a 21-day program to enhance first responder resilience and tested the program with promising results. Every day over the course of 21 days, participants received a keyword which encouraged them to follow certain practices for the day, such as grit, calm, empathy, and gratitude. They also did 5 minutes of controlled breathing exercises, short readings on the keywords, reflections for the day, and an evening gratitude practice. Gratitude was incorporated into the program to increase sleep quality, life satisfaction, and decrease risk of depressive symptoms. In total, the practice work took only 15 minutes a day, accounting for the busy schedules of typical first responders. The participants responded to the 21 day course well, and a majority indicated that they would continue to use the practices they learned during the course of the program.[17]

Programs such as this one, and other resilience programs, would be beneficial for all first responders to incorporate into their lifestyles to increase resilience against developing mental health issues, promote the necessity of managing one’s mental health and reduce stigma in those suffering with PTSD, depression, anxiety and other work-related mental health disorders. 

If one has been suffering from any mental health disorder due to traumatic stress, such as PTSD or ASD, or is experiencing feelings of heightened anxiety or suicidal ideations, it is crucial to contact a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) for guidance and support.

Contributed by: Ananya Udyaver

Editor: Jennifer (Ghahari) Smith, Ph.D.

References 

1 Heyman, M., Dill, J., & Douglas, R. (2018, April). The ruderman white paper on mental health and suicide of first ... https://firefightermentalhealth.org/system/files/First%20Responder%20White%20Paper_Final.pdf 

2 Stanley, I., Hom, M., & Joiner, T. (2015, December 12). A systematic review of suicidal thoughts and behaviors among police officers, firefighters, emts, and Paramedics. Clinical Psychology Review. https://www.sciencedirect.com/science/article/abs/pii/S0272735815300684?via%3Dihub 

3 Bond, A., & Anestis, M. (2021, October 26). Understanding capability and suicidal ideation among first responders. https://www.tandfonline.com/doi/full/10.1080/13811118.2021.1993397 

4 Lewis-Schroeder, N. F., Kieran, K., Murphy, B. L., Wolff, J. D., Robinson, M. A., & Kaufman, M. L. (2018). Conceptualization, Assessment, and Treatment of Traumatic Stress in First Responders: A Review of Critical Issues. Harvard review of psychiatry, 26(4), 216–227. https://doi.org/10.1097/HRP.0000000000000176 

5 Feldman, T. R., Carlson, C. L., Rice, L. K., Kruse, M. I., Beevers, C. G., Telch, M. J., & Josephs, R. A. (2021). Factors predicting the development of psychopathology among first responders: A prospective, longitudinal study. Psychological Trauma: Theory, Research, Practice, and Policy, 13(1), 75–83. https://doi.org/10.1037/tra0000957 

6 Lewis-Schroeder, N. F., Kieran, K., Murphy, B. L., Wolff, J. D., Robinson, M. A., & Kaufman, M. L. (2018). 

7 Ibid.

8 Ibid.

9 Bond, A., & Anestis, M. (2021, October 26). 

10 Heyman, M., Dill, J., & Douglas, R. (2018, April).

11 Stanley, I., Hom, M., & Joiner, T. (2015, December 12).

12 Jones S, Agud K, McSweeney J. (2020) Barriers and Facilitators to Seeking Mental Health Care Among First Responders: “Removing the Darkness.” Journal of the American Psychiatric Nurses Association. 26(1):43-54. doi:10.1177/1078390319871997

13 Heyman, M., Dill, J., & Douglas, R. (2018, April).

14 Jones S, Agud K, McSweeney J. (2020)

15 Lewis-Schroeder, N. F., Kieran, K., Murphy, B. L., Wolff, J. D., Robinson, M. A., & Kaufman, M. L. (2018). 

16 Joyce, S., Tan, L., Shand, F., Bryant, R., & Harvey, S. (2019). Can resilience be measured and used to predict mental... : Journal of Occupational and Environmental Medicine. LWW. https://journals.lww.com/joem/abstract/2019/04000/can_resilience_be_measured_and_used_to_predict.4.aspx 

17 Thompson, J., & Drew, J. M. (2020, July 27). Warr;OR21: A 21-day program to enhance first responder resilience and mental health. Frontiers. https://www.frontiersin.org/articles/10.3389/fpsyg.2020.02078/full 

TREATING BODY DYSMORPHIA: THE CASE FOR MORE RESEARCH

When Beauty Is the Beast

January 2019. My workouts get longer and my meals get smaller along with my waist. Subtract twelve pounds but the mirror still shows me a monster. Acne, dark spots, rolls of fat— I am a billboard displaying my worst nightmares. At least that’s what my brain tells me. Everything around me proceeds as normal: boys ask me out, girls ask me how, and everyone calls me beautiful. Why does my brain refuse to see me as I actually am? 

The DSM-5 characterizes body dysmorphic disorder (BDD) as a fixation on perceived imperfections in physical appearance that are insignificant or unnoticeable to others.[1] This occurs as a consequence of abnormal visual processing in the brain that results in an increased focus on minute details and an inability to see the bigger picture.[2] BDD often co-occurs with major depressive disorder (MDD) as well as with suicidal thoughts and tendencies. It is also associated with anxiety, social avoidance, neuroticism, and perfectionism.[3] About 1.7% to 2.9% of the general population is impacted by BDD, which is equivalent to about 1 in 50 people. In the US alone, approximately 5 to 10 million people have this disorder.[4] BDD impacts women more frequently than men— with women comprising roughly 60% of the impacted population.[5] However, BDD still remains quite under-diagnosed and the true prevalence may not be known at present.[6]

Photo credit: Sanjana Bakre

Current Treatments for BDD

The two most common treatments for BDD are cognitive behavioral therapy (CBT) and selective serotonin re-uptake inhibitors (SSRIs). Combining both is the most common method of treatment used today.[7] In terms of alleviating symptoms and how long effects last beyond completion of treatment, CBT appears to be the most effective and lasting treatment available. Continuous use of SSRIs is required to alleviate symptoms in the long run.[8] However, neither treatment has yet been proven to be both effective and permanent.[9]

Cognitive Behavioral Therapy (CBT) for Treating BDD

CBT techniques focus on curbing damaging behaviors and thoughts by helping individuals perceive themselves more holistically beyond small imperfections. This helps alter the abnormal visual processing caused by BDD that involves heightened focus on minute details. As it targets this key mechanism of the disorder, CBT remains the recommended treatment for BDD today.[10] Moreover, CBT encourages patients to face their fears— such as going out in public without concealing their perceived flaws— and ultimately aims to adapt patients’ belief systems to be more flexible and self-accepting.[11]  

Research suggests that CBT is moderately effective in treating BDD, both in terms of improvement and permanence: it has been found to reduce symptoms between 50-78% and last at least 2 months.[12] In a study by Wilhelm et al. (2014), after 24 weeks of CBT, the Yale-Brown Obsessive-Compulsive Scale modified for Body Dysmorphic Disorder (BDD-YBOCS) scores of all participants decreased by 30% or more; this margin that indicates that symptoms had “much improved”.[13,14] In another study by Rosen et al. (1995), after undergoing 8 weeks of CBT, participants scored significantly lower on the Body Dysmorphic Disorder Examination (BDDE); these scores remained constant even 4.5 months after treatment was stopped.[15] These results suggest that the effects of CBT are somewhat lasting, likely due to alterations to the negative belief systems and perceptions that directly reinforce BDD. 

However, there is a lack of research confirming that the positive effects of CBT last beyond 6 months.[16] Longitudinal observation in one study conducted by Krebs et al. (2017) supported the opposite notion: adolescents continued to have significant symptoms of BDD and were still at risk for related, dangerous behaviors a year after CBT was stopped.[17] Therefore, it can be reasonably concluded that CBT is, at best, moderately effective as it does not completely alleviate symptoms and appears to be rather short-term in its effects. Continuous CBT is required in order for BDD patients to remain symptom-free in the long-term.[18]

SSRIs for Treating BDD

SSRIs are antidepressant drugs that alleviate a majority of BDD symptoms by altering neurotransmission in the brain. They have been proven to be the most effective antidepressants for treating BDD.[19] SSRIs prolong the effects of the neurotransmitter serotonin by preventing its re-uptake in synapses, inducing feelings of positivity and relaxation.[20] These are generally prescribed to make BDD patients’ daily lives easier and to make them more receptive to CBT.[21]

SSRIs improve both the symptoms and the mechanisms of BDD, reducing anxiety and compulsive behaviors while also altering perceptions of flaws— as with most medication, it is an effective treatment but there is no scope for continuity of the positive effects after treatment is stopped.[22,23] According to research, SSRIs can result in reductions across all elements of the BDD-YBOCS.[24] Patients who took SSRIs also showed significant improvements in their scores on BDD modification of the Fixity of Beliefs Questionnaire for OCD, suggesting meaningful changes in their beliefs regarding physical appearance. These changes are important as they undermine the very maintenance mechanism of BDD.[25] These alterations likely occur in response to improvements in one’s overall mood as well as a reduction in obsessive thoughts.  However, there is a lack of research observing the long-term effects of SSRI treatment beyond 6 months, let alone what occurs after these medications are stopped. A study by Hollander et al. (2008) has been published on the effects of continuing treatment for 6 months and it was found that 8% relapsed and 60% did not improve further.[26] This highlights that while SSRIs may prevent relapse, it only causes improvements for a short period of time.[27] Overall, SSRIs can be considered extremely effective in alleviating symptoms of BDD; however, this effect is ephemeral so SSRIs must be taken continuously in order be considered a permanent treatment for BDD.[28] While SSRIs are considered fairly safe to take long-term, they also have adverse side effects such as weight gain, gastrointestinal issues, and sexual dysfunction. Additionally, there is a lack of empirical data identifying the impacts of taking these beyond 10 years, let alone indefinitely.[29,30]

The Future of BDD Treatment

Overall, both CBT and SSRIs alleviate symptoms— with SSRIs causing greater improvements— for a few months at least. Although SSRIs can technically continue to prevent symptoms if continuously taken, they don’t necessarily allow patients to remain non-reliant on treatment and their long-term side effects are relatively unknown. It appears as though CBT in conjunction with SSRIs, is the most effective existing treatment. 

Unfortunately, research by Rossell et al. (2017) suggests that these treatments only result in a 50-70% improvement because they do not address new findings regarding other mechanisms of BDD, such as abnormal connectivity between brain structures and correlations with GABA receptors.[31] Additionally, a lacuna in BDD-specific research has made it quite difficult to draw conclusions about the efficacy of existing treatments— there are less than 10 published studies investigating each of these treatments, and none of them explore their long-term effects beyond 6 months.[32] At present, more research into BDD treatment is needed not only to better evaluate the efficacy of current treatments, but also so that these can be further developed and optimized. Further research into the mechanisms of BDD can also potentially aid these efforts by providing more guidance in the development of new treatments. Given that BDD and its co-morbidities can severely interfere with people’s lives, future research efforts to inform and advance BDD treatments are essential. 

Contributed by: Sanjana Bakre

Editor: Jennifer (Ghahari) Smith, Ph.D.

If you think you may be suffering from BDD, please reach out to a licensed mental health professional for guidance/assistance.

REFERENCES

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

2  Feusner, J. D., Moody, T., Hembacher, E., Townsend, J., Mckinley, M., Moller, H., & Bookheimer, S. (2010). Abnormalities of Visual Processing and Frontostriatal Systems in Body Dysmorphic Disorder. Archives of General Psychiatry, 67(2), 197. https://doi.org/10.1001/archgenpsychiatry.2009.190

3 American Psychiatric Association (2013) 

4 Phillips, K. A. (n.d.). Prevalence of BDD. International OCD Foundation. Retrieved September 28, 2022, from https://bdd.iocdf.org/professionals/prevalence/#:~:text=Body%20Dysmorphic%20Disorder%20affects%201.7,United%20States%20alone%20have%20BDD

5 Phillips KA, Diaz SF. Gender differences in body dysmorphic disorder. J Nerv Ment Dis. 1997 Sep;185(9):570-7. doi: 10.1097/00005053-199709000-00006. PMID: 9307619.

6 Phillips, K. A. (n.d.). Who gets BDD? International OCD Foundation. Retrieved September 28, 2022, from https://bdd.iocdf.org/about-bdd/who-gets/

7 Hollander, E., Allen, A., Kwon, J., Aronowitz, B., Schmeidler, J., Wong, C., & Simeon, D. (1999). Clomipramine vs Desipramine Crossover Trial in Body Dysmorphic Disorder. Archives of General Psychiatry, 56(11), 1033. https://doi.org/10.1001/archpsyc.56.11.1033

8 Phillipou, A., Rossell, S. L., Wilding, H. E., & Castle, D. J. (2016). Randomised controlled trials of psychological & pharmacological treatments for body dysmorphic disorder: A systematic review. Psychiatry Research, 245, 179–185. https://doi.org/10.1016/j.psychres.2016.05.062

9 Beilharz, F., & Rossell, S. L. (2017). Treatment Modifications and Suggestions to Address Visual Abnormalities in Body Dysmorphic Disorder. Journal of Cognitive Psychotherapy, 31(4), 272–284. https://doi.org/10.1891/0889-8391.31.4.272

10 Phillipou et al. (2016)

11 Beilharz et al. (2017)

12 Ibid.

13 Wilhelm, S., Phillips, K. A., Didie, E., Buhlmann, U., Greenberg, J. L., Fama, J. M., … Steketee, G. (2014). Modular Cognitive-Behavioral Therapy for Body Dysmorphic Disorder: A Randomized Controlled Trial. Behavior Therapy, 45(3), 314–327. https://doi.org/10.1016/j.beth.2013.12.007

14 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(3), 205–208. https://doi.org/10.1016/j.jocrd.2014.04.004

15 Rosen, J. C., Reiter, J., & Orosan, P. (1995). Cognitive-behavioral body image therapy for body dysmorphic disorder. Journal of Consulting and Clinical Psychology, 63(2), 263–269. https://doi.org/10.1037/0022-006x.63.2.263

16 Harrison, A., Cruz, L. F. D. L., Enander, J., Radua, J., & Mataix-Cols, D. (2016). Cognitive-behavioral therapy for body dysmorphic disorder: A systematic review and meta-analysis of randomized controlled trials. Clinical Psychology Review, 48, 43–51. https://doi.org/10.1016/j.cpr.2016.05.007

17 Krebs, G., Cruz, L. F. D. L., Monzani, B., Bowyer, L., Anson, M., Cadman, J., … Mataix-Cols, D. (2017). Long-Term Outcomes of Cognitive-Behavioral Therapy for Adolescent Body Dysmorphic Disorder. Behavior Therapy, 48(4), 462–473. https://doi.org/10.1016/j.beth.2017.01.001

18 Ibid. 

19 Hollander et al. (1999)

20 National Health Service UK. (2021, December 8). Overview - Selective serotonin reuptake inhibitors (SSRIs). NHS UK. Retrieved September 22, 2022, from https://www.nhs.uk/mental-health/talking-therapies-medicine-treatments/medicines-and-psychiatry/ssri-antidepressants/overview/#:~:text=It's%20thought%20to%20have%20a,messages%20between%20nearby%20nerve%20cells

21 Greenberg, J. L., Wilhelm, S., Feusner, J., Phillips, K. A., & Szymanski, J. (2019, January 23). How is BDD Treated? International OCD Foundation. https://bdd.iocdf.org/about-bdd/how-is-bdd-treated

22 Phillips, K. A. (2005). The broken mirror: understanding and treating body dysmorphic disorder. Oxford University Press.

23 Phillips, K. A., & Hollander, E. (2008). Treating body dysmorphic disorder with medication: Evidence, misconceptions, and a suggested approach. Body Image, 5(1), 13–27. https://doi.org/10.1016/j.bodyim.2007.12.003

24 Ibid. 

25 Hollander et al. (1999)

26 Phillips et al. (2008)

27 Jain S, Grant JE, Menard W, Cerasoli S, Phillips KA. A chart-review study of SRI continuation treatment versus discontinuation in body dysmorphic disorder. Abstracts, National Institute of Mental Health NCDEU 44th Annual Meeting; Phoenix, AZ. 2004. p. 231.

28 Phillipou et al. (2016)

29 National Collaborating Centre for Mental Health (UK). Depression in Adults with a Chronic Physical Health Problem: Treatment and Management. Leicester (UK): British Psychological Society (UK); 2010. NICE Clinical Guidelines, No. 91.

30 Peterson A. (2019) New Concerns Emerge About LongTerm Antidepressant Use. Anxiety and Depression Association of America. Retrieved September 28, 2022, from https://adaa.org/sites/default/files/New%20Concerns%20Emerge%20About%20Long-Term%20Antidepressant%20Use.pdf

31 Beilharz et al. (2017)

32 Phillipou et al. (2016)