Reliability and Validity of the Self-Report Version of the Yale-Brown Obsessive-Compulsive Scale Modified for Body Dysmorphic Disorder

Abstract

Despite its frequent use in research studies, the self-report version of the Yale-Brown Obsessive-Compulsive Scale modified for Body Dysmorphic Disorder (BDD-YBOCS-SR) is yet to be formally validated. The present investigation sought to examine the psychometric properties of the BDD-YBOCS-SR across three different samples. In Study 1 (N = 847), we sought to explore the factor structure of the BDD-YBOCS-SR. In addition, we evaluated the convergent and divergent validity with similar self-report measures. In Study 2 (N = 187), the convergence of the BDD-YBOCS-SR with reactivity to an in vivo appearance-related task was observed. In Study 3, we compared scores on the BDD-YBOCS-SR between a clinical sample of individuals with BDD (n = 50) and a “healthy” control sample (n = 51). We further observed the BDD-YBOCS-SR’s sensitivity to treatment and convergence with the rater-administered version in the clinical sample. The BDD-YBOCS-SR demonstrated strong psychometric properties across all three studies. Scores on the BDD-YBOCS-SR were found to be strongly associated with appearance anxiety, reactivity to the appearance task, and the rater-administered BDD-YBOCS. The present investigation provides support for the BDD-YBOCS-SR’s utility in measuring body dysmorphic symptom severity for use in research and clinical settings.

Keywords

body dysmorphic disorder measurement self-report psychometrics

The Yale-Brown Obsessive-Compulsive Scale modified for Body Dysmorphic Disorder (BDD-YBOCS; Phillips et al., 1997) is a semi-structured, rater-administered measure that consists of 12 items designed to measure body dysmorphic disorder (BDD) symptom severity in the past week and is considered the gold standard measure of BDD symptom severity (Phillips et al., 2014). The measure was initially adapted from the Yale-Brown Obsessive-Compulsive Scale, the most widely used rater-administered assessment of obsessive-compulsive disorder (OCD) symptomatology, due to the conceptual overlap between OCD and BDD (Goodman et al., 1989). Since its initial development, the rater-administered BDD-YBOCS (BDD-YBOCS-RA) has been used as the primary measure of BDD severity in research studies evaluating treatment outcomes (e.g., clinical trials testing the efficacy of pharmacological and cognitive–behavioral interventions; Harrison et al., 2016; Phillips & Najjar, 2003; Wilhelm et al., 2014, 2019)

The 12 items of the BDD-YBOCS-RA seek to establish the severity of the individual’s symptom expression from “none” to “extreme.” The first 5 items assess preoccupation with one’s appearance (e.g., time perseverating on appearance “flaw,” interference in psychosocial functioning and distress due to perceived appearance defects, degree to which individual actively tries to resist engaging in appearance-related thoughts, and the degree of perceived control over these preoccupations). Items 6 through 10 assess repetitive, ritualistic behaviors anchored to BDD-related concerns (e.g., checking reflection, applying products, excessive grooming, reassurance seeking, etc.). Item 11 assesses insight into one’s illness (i.e., degree to which the individual recognizes the problematic and unnecessary role of daily symptoms in their lives), and Item 12 assesses psychosocial avoidance related to BDD symptoms.

The BDD-YBOCS-RA has largely demonstrated good psychometric properties (Phillips et al., 1997, 2014). The original validation study showed strong reliability (i.e., interrater, test–retest, and internal consistency), convergent and divergent validity, and sensitivity to change in a sample of treatment seeking individuals with BDD (Phillips et al., 1997). Factor analyses revealed a three-factor structure mapping onto (1) Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association, 1994) criteria for BDD (i.e., excessive preoccupation with a slight or imperceptible physical concern), (2) appearance-related compulsions (e.g., repeated attempts to check, fix and/or hide physical concern), and (3) efforts to resist and control appearance-related symptoms (i.e., preoccupation and associated behavioral expressions). Following updated diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association [APA], 2013), the BDD-YBOCS-RA was reevaluated in a second study, further demonstrating its psychometric properties in a treatment sample of individuals with BDD (Phillips et al., 2014). Notably, this study found a different factor structure of the BDD-YBOCS-RA, with two factors being identified (i.e., [1] core DSM-5 criteria and [2] avoidance as well as DSM-5 criteria). Most of the items mapped onto both of these factors, suggesting a one-factor solution, but a few of the items that were related to avoidance of BDD symptoms mapped onto a distinct factor along with the other symptoms. Despite different findings in relation to factor structure, these prior studies demonstrate the clinical and research utility of the BDD-YBOCS-RA. Specifically, the BDD-YBOCS-RA provides an empirically derived cut-off score (i.e., ≥ 20) of BDD, gathers nuanced objective data of symptoms change throughout treatment, and allows for more direct comparison across individuals with regard to the severity of BDD symptoms and treatment efficacy (Phillips et al., 2014; Wilhelm et al., 2014, 2019).

Despite the strong reliability, convergent validity, and clinical utility of the BDD-YBOCS-RA, the use of the measure requires valuable rater time and extensive training to successfully implement. Specifically, interviews can require anywhere from 10 to 40 min to complete, depending on symptom complexity and level of rater experience; best practices include rigorous training from experts in the field and demonstration of interrater reliability on measure administration and nuances of symptom evaluation to ensure adherence and protect against bias or rater drift. Over the past decade, practical considerations alongside the growing use of online studies to reach a broader range of participants have led investigators to more commonly implement self-report versions of the BDD-YBOCS in their research (e.g., Marques, LeBlanc, et al., 2011; Marques, Weingarden, et al., 2011; Summers et al., 2017, 2020; Wilver et al., 2020). In addition to differing administration formats, another key difference between the BDD-YBOCS-RA and the BDD-YBOCS-Self Report (BDD-YBOCS-SR) is that many researchers have chosen to only utilize the first 10 items (i.e., those assessing appearance preoccupation and associated rituals) and omit Items 11 and 12 (assess the level of insight and avoidance, respectively), as the latter two constructs can be more difficult for certain patients to accurately self-report (Clerkin & Teachman, 2009; Marques, Weingarden, et al., 2011; Summers et al., 2017, 2020; Wilhelm et al., 1999). With the exclusion of these 2 items, the measure is still scored by summing the item totals, but the cutoff score for clinical significance has been 16 rather than 20. The studies that have used the 10-item BDD-YBOCS-SR have reported good to excellent internal consistencies (α’s = .70-.96), and they have utilized the measure in the context of treatment and experimental manipulation seeking to modify BDD symptoms. These studies demonstrated medium to large effects (η_p²’s = .30–.81; Cohen’s ds = .39–.73) in reductions of BDD symptoms as measured by the BDD-YBOCS-SR, indirectly demonstrating the measure’s sensitivity to treatment and construct validity (Summers & Cougle, 2016, 2018; Wilver et al., 2020).

Despite its use in published BDD studies, the BDD-YBOCS-SR has not been psychometrically evaluated. In addition, the BDD-YBOCS-SR has been increasingly utilized despite the availability of other self-report measures of BDD severity such as the Body Dysmorphic Disorder Questionnaire (Phillips et al., 1995), Dysmorphic Concern Questionnaire (Mancuso et al., 2010), Body Image Disturbance Questionnaire (Cash, 2008), and the Body Dysmorphic Disorder Symptom Scale (Wilhelm et al., 2016). Given that the rater-administered BDD-YBOCS is the gold standard measure of BDD severity, maintaining item consistency with a self-report version of the measure allows for comparisons across studies that utilized the rater-administered BDD-YBOCS and provides a seemingly valid and reliable measure of BDD symptoms severity. However, a formal evaluation of the psychometrics of the BDD-YBOCS-SR is necessary.

The goal of the present investigation was to evaluate the psychometric properties of the BDD-YBOCS-SR. Given the measure’s potential utility as a reliable and relatively comprehensive measure of BDD symptom severity, psychometric evaluation evidencing the validity and reliability of the BDD-YBOCS-SR could enhance its implementation cases in settings where trained raters are either unavailable (e.g., in medical settings that wish to screen for appearance disorders and enhance measurement-based care initiatives) or impractical to use (e.g., online studies). We took a multimethod approach to examining the psychometric properties of this measure across three studies. In Study 1, we sought to investigate the factor structure of the 10-item BDD-YBOCS-SR and its relationship with conceptually similar self-report measures. In Study 2, we sought to validate the BDD-YBOCS-SR by investigating its association with response to an in vivo appearance-related task. In Study 3, we sought to compare the rater-administered and self-report versions of the BDD-YBOCS in a clinical sample undergoing online treatment as well as compare the clinical sample’s self-report scores to those of a healthy control sample.

Study 1

In Study 1, we sought to first cross-validate the two-factor structure of the BDD-YBOCS-SR with prior data on the factor structure of the rater-administered BDD-YBOCS using confirmatory factor analysis (CFA; Phillips et al., 2014). To further explore the factor structure of the BDD-YBOCS-SR, the present sample was randomly split in half to conduct factor analyses using an exploratory factor analysis (EFA) to CFA approach (Swami & Barron, 2019). We also investigated the convergent and divergent validity of the BDD-YBOCS-SR with other clinical measures.

Method

Participants and Procedures

Study participants (N = 840) included psychology undergraduate students at a large southeastern university taking part in a larger study investigating appearance-related concerns. Participants were informed that the study included questions about their mood, thoughts, and behaviors and that the study sought to determine factors related to appearance concerns and BDD. To promote variability within the sample, inclusion criteria were broad; students could participate in the study if they were between the ages of 18 and 65 and fluent in English. The mean age of study participants was 19.44 (SD = 2.2) years. A majority of the sample identified as women (n = 670; 79.8%). With respect to race/ethnicity, the majority of the sample identified as White (n = 693; 82.5%), 207 (24.6%) identified as Hispanic, 115 (13.7%) identified as Black, 56 (6.7%) identified as Asian, 6 (0.7%) identified as Hawaiian or Pacific Islander, 9 (1.1%) identified as Native American or Alaskan Native, and 27 (3.2%) identified as “Other.”

Informed consent was obtained prior to study participation by a trained research assistant. Study procedures included completing a battery of questionnaires on a laboratory computer. To maintain the anonymity of participants’ identities, identifying information was stored separately from study data, and participants were not required to disclose any identifying information within study questionnaires. All participants were debriefed about the study purpose after completion and compensated with course credit for their participation. All procedures were approved by the university institutional review board where the research was conducted.

Measures

Yale-Brown Obsessive-Compulsive Scale Modified for BDD–Self Report

The 10-item BDD-YBOCS-SR (adapted from Phillips et al., 1997; See Appendix) was administered to assess the severity of BDD symptoms over the past week (i.e., time, distress, interference, degree of resistance, and perceived control of one’s thoughts and behaviors related to appearance concerns). Items are rated from 0 (No symptomatology) to 4 (Extreme symptomatology) with total scores ranging from 0 to 40. Prior research has demonstrated good to excellent internal consistency (αs = .70–.96) in community and clinical samples (Marquez et al., 2011a; Summers & Cougle, 2016).

Appearance Anxiety Inventory (AAI)

The Appearance Anxiety Inventory (AAI) is a 10-item self-report measure of cognitive and behavioral features of body image anxiety typical of individuals with BDD (Veale et al., 2014). Items are rated on a 5-point Likert-type scale and summed to create a total score ranging from 0 to 40. Scores of 20 and higher indicate clinically significant appearance concerns, and a score of 13 is average and indicative of appearance concerns commonly observed in the general population (Mastro et al., 2016). The AAI has demonstrated good internal consistency (α = .86; Veale et al., 2014) and was excellent (α = .92) in the present sample.

Center for Epidemiologic Studies Depression Scale

The Center for Epidemiologic Studies Depression Scale (CES-D) is a 20-item measure of depressive symptoms in the past week (e.g., “I haven’t been able to pay attention to things this week”; Radloff, 1977). Items are rated on a scale from 0 (Rarely or none of the time [less than 1 day]) to 3 (Most or all of the time[5-7 days]) with total scores ranging from 0 to 60. Higher scores are indicative of greater depressive symptom severity. The CES-D has demonstrated strong psychometric properties in prior studies (αs = .85–.95; Radloff, 1997), and the internal consistency of the CES-D in the present sample was adequate (α = .79).

The Eating Disorder Inventory (EDI)

The Eating Disorder Inventory (EDI) is a multiscale measure of eating disorder pathology consisting of 64 items (e.g., “I stuff myself with food.”; “I think that my thighs are too large.”; Garner et al., 1983). Items are rated from 1 (Never) to 6 (Always) to determine the frequency of each item. The EDI consists of 8 subscales that measure different aspects of eating pathology, but for the purpose of this study, only the drive for thinness and bulimia scales were included. The psychometric properties of the EDI have been studied extensively and validated demonstrating strong convergent validity and internal consistency in clinical and control samples (αs = .76–.96; Clausen et al., 2011). The internal consistency of the drive for thinness scale (α = .92) and bulimia scale (α = .88) were excellent.

Results

Confirmatory Factor Analyses

The CFA of the BDD-YBOCS-SR was conducted using the lavaan package (Rosseel, 2012) in R version 4.1.1 (R Core Team, 2020). The data were screened for multivariate normality using Mardia’s coefficient (Mardia, 1970) and were found to exhibit a non-normal distribution (kurtosis = 18.21). In addition, the items are scored on a 5-point ordered scale; thus, diagonally weighted least square mean and variance adjusted (WLSMV) estimation was utilized as the estimator. There were no missing data patterns observed. Model fit was examined through several fit indices including chi square test of exact model fit, Comparative Fit Index (CFI; Bentler, 1990), the Tucker-Lewis Index (TLI; Tucker & Lewis, 1973), Root Mean Square Error of Approximation (RMSEA; Browne & Cudeck, 1992), and Standardized Root Mean Square Residual (SRMR; Hu & Bentler, 1999).

Based on a validation study of the 12-item, rater-administered BDD-YBOCS (Phillips et al., 2014), a two-factor model of the BDD-YBOCS-SR was tested. In the original validation study, most of the items (i.e., 1,3,4,5,6,7,8,9,10, and 11) loaded onto one factor and 8 items (i.e., 1, 2, 3, 5, 6, 7, 8, and 12) loaded onto a second factor, with 6 of these items loading onto both factors in a clinical sample of individuals with BDD. This same model was tested with the 10-item BDD-YBOCS-SR. The two factors were allowed to covary. Results of the present study indicated a good approximate model fit, χ²(45) = 2,318.05, p < .001, CFI = .94, TLI = .90, SRMR = 0.035, RMSEA = .082 95% confidence interval (CI): [0.071, 0.094]. Both CFI and TLI were above the threshold of good fit (i.e., .90; Bentler, 1990; Tucker & Lewis, 1973) but not above the threshold of excellent fit (i.e., .95). The SRMR was below the threshold of good fit (i.e., .08; Hu & Bentler, 1999), but the RMSEA was slightly above the threshold of good fit (i.e., .08; Browne & Cudeck, 1992). Table 1 presents a summary of standardized estimates of the factor loadings. The two factors were found to be strongly correlated (r = .70).

Table 1.

Summary of Factor Analyses on the BDD-YBOCS-SR (N = 840).

		Phillips et al. (2014) model (N = 840)		EFA loadings (n = 420)			Three-factor model (n = 420)
Items		Factor 1	Factor 2	Factor 1	Factor 2	Factor 3	Factor 1	Factor 2	Factor 3
1.	Time occupied by thoughts about appearance concerns	0.10	0.57	0.59	—	—	0.70	—	—
2.	Interference due to thoughts about appearance concerns	—	0.65	0.74	—	—	0.73	—	—
3.	Distress associated with thoughts about appearance concerns	0.22	0.49	—	0.48	—	—	0.75	—
4.	Resistance against thoughts of appearance concerns	0.60	—	—	0.52	—	—	0.64	—
5.	Degree of control over thoughts about appearance concerns	0.51	0.22	—	0.70	—	—	0.84	—
6.	Time spent in activities related to appearance concerns	0.21	0.24	0.60	—	—	0.62	—	—
7.	Interference due to activities related to appearance concerns	0.17	0.46	0.64	—	—	0.76	—	—
8.	Distress associated with activities related to appearance concerns	0.59	0.13	—	—	0.51	—	—	0.81
9.	Resistance against compulsions	0.76	—	—	—	0.76	—	—	0.59
10.	Degree of control over compulsive behavior	0.76	—	—	—	0.41	—	—	0.94

Note. Phillips et al. Factor 1 represents DSM-5 symptoms; Factor 2 represents distress due to symptoms. EFA and three-factor: Factor 1 represents time and interference due to BDD-related thoughts and activities; Factor 2 represents distress and control over BDD thoughts; Factor 3 distress and control over BDD activities. Both CFA model estimates are standardized parameters. DSM-5 = Diagnostic and Statistical Manual of Mental Disorders (5th ed); CFA = confirmatory factor analysis; EFA = exploratory factor analysis; BDD = Body Dysmorphic Disorder.

Given that the BDD-YBOCS-SR does not contain 2 items that were included in previous factor analyses of the original, rater-administered BDD-YBOCS (i.e., those assessing insight and avoidance), we endeavored to implement a two-step analytic strategy that would offer a robust validation test. Specifically, the sample was randomly split into equal parts (each n = 420) and an EFA-to-CFA approach was used to evaluate the factor structure of the BDD-YBOCS-SR (as recommended by Swami & Barron, 2019). To extract the optimal number of factors, a stepwise approach was adopted. First, the sample was analyzed to determine if it would be sufficient for these analyses. The Kaiser–Meyer–Olkin Measure of sampling adequacy was .90, indicating the sample was appropriate for this analysis. Second, the number of factors to extract was determined through Eigenvalues greater than one, scree test, and parallel analyses. Initial evaluation of Eigenvalues and the scree plot suggested a one factor solution; however, parallel analysis revealed that three factors should be extracted and retained (Original Eigenvalues: [1] 4.45, [2] 0.42, [3] 0.23, [4] 0.07; Simulated Eigenvalues: [1] 4.10, [2] 0.17, [3] 0.05, [4] -0.06). Principal axis factoring was conducted with three factors specified. All items displayed distinctive factor loadings above .40 on these three factors (Table 1). Bartlett’s test of sphericity was significant, χ²(45) = 1,780.62, p <.001 indicating that the items were highly correlated. Factor 1 captured psychosocial interference and time dedicated to BDD symptoms overall (i.e., disordered thoughts and activities). Factor 2 captured distress and perceived control over BDD-related thoughts (obsessional symptoms), while Factor 3 captured distress and perceived control over BDD-related activities (compulsive symptoms).

Following the EFA, a CFA was conducted with the second half of the sample to confirm this factor structure. Mardia’s coefficient for normality was reevaluated in this subsample, and the data were found to not be multivariate normal. WLSMV estimation was used as the estimator in the subsequent analysis. Results indicated good model fit, χ²(28) = 67.12, p < .001, CFI = .97, TLI = .95, SRMR = 0.033, RMSEA = .058 95% CI [0.040, 0.076]. Both CFI and TLI were above the threshold of excellent fit (i.e., .95). The SRMR and RMSEA were below the threshold of good fit (i.e., .08; Browne & Cudeck, 1992; Hu & Bentler, 1999). Factor 1 was highly correlated with Factor 2 (r = .88) and Factor 3 (r =.76). Factors 2 and 3 were also highly correlated (r = .78). Altogether, the EFA-to-CFA approach suggests that a 3-factor structure best describes the BDD-YBOCS-SR. Table 2 presents a summary of standardized estimates of the factor loadings.

Table 2.

Study 1—Zero Order Correlations (N = 840).

Variables	M	SD	1	2	3	4	5	6	7
1. BDD-YBOCS-SR	12.59	6.50	—
2. BDD-YBOCS-F1	4.72	2.53	.88*	—
3. BDD-YBOCS-F2	3.68	2.28	.88*	.70*	—
4. BDD-YBOCS-F1	4.19	2.62	.87*	.61*	.65*	—
5. AAI	15.67	9.35	.75*	.72*	.64*	.60*	—
6. CES-D	17.23	11.51	.60*	.57*	.53*	.47*	.59*	—
7. EDI-thinness	22.12	9.74	.57*	.55*	.51*	.44*	.65*	.40*	—
8. EDI-Bulimia	14.37	7.00	.51*	.46*	.45*	.41*	.54*	.45*	.62*

Note. M = Mean; SD = standard deviation; BDD-YBOCS-SR = Yale–Brown Obsessive Compulsive Scale modified for Body Dysmorphic Disorder-Self Report; BDD-YBOCS-F1 = Factor 1 (time/interference BDD thoughts and compulsions); BDD-YBOCS-F2 = Factor 2 (distress and control of BDD thoughts); BDD-YBOCS-F3 = Factor 3 (distress and control of BDD activities); AAI = Appearance Anxiety Inventory; CES-D = Center of Epidemiologic Studies Depression Scale; EDI-Thinness = Eating Disorder Inventory-Drive for thinness; EDI-Bulimia = Eating Disorder Inventory-Bulimia.

p <.001.

Internal Consistency

Cronbach’s α was calculated to observe the internal consistency of the BDD-YBOCS-SR. The internal consistency of the overall BDD-YBOCS-SR was good (α = .89; women α = .89, men α = .87). The internal consistency of three factors were adequate to good (i.e., factor 1 α = .80; factor 2 α = .77; factor 3 α = .75). Individual item-level descriptive and correlations can be found in Supplementary Table S1.

Validity Analyses and Associations With Clinical Symptoms

Descriptive statistics as well as zero-order correlation analyses of all study variables can be found in Table 2. The total score of the BDD-YBOCS-SR was positively correlated with appearance anxiety, demonstrating convergent validity. In addition, the BDD-YBOCS-SR was positively correlated with depressive symptoms, drive for thinness, and bulimic symptoms. Similarly, the three factors were strongly correlated with appearance anxiety, depressive symptoms, drive for thinness, and bulimic symptoms. To test divergent validity, we calculated the differences between correlations by converting them to z scores and conducting t tests to statistically compare the relative strength of the observed associations. We adopted this approach given that BDD is highly comorbid with depression, which can artificially inflate the relationship between BDD symptoms and general negative affect and distress (Phillips et al., 2014; Summers et al., 2022). A similar approach has been adopted in examining the rater-administered BDD-YBOCS (Phillips et al., 2014). The correlation between the BDD-YBOCS-SR and appearance anxiety (r = .75) was significantly greater than the correlations between the BDD-YBOCS-SR and depression (r = .60; t = 7.32, p <.001), drive for thinness (r = .57; t = 9.31, p <.001), and bulimic symptoms (r = .51; t = 10.74, p <.001).

Study 2

In Study 2, we sought to further validate the BDD-YBOCS-SR in a separate sample of undergraduate students (N = 187) by investigating its prediction of reactivity to an in vivo appearance-related stressor task.

Method

Participants and Procedures

Similar to Study 1, participants were recruited from a pool of psychology students at the same large southeastern university in the United States. The study was described similarly to Study 1 as seeking to observe mood, thoughts, and behaviors. Eligible participants included students between the ages of 18 and 65 years who spoke fluent English. The sample consisted of 187 participants with a majority of the sample identifying as women (n = 126; 67.4%). The age of the sample ranged from 18 to 30 years old (M = 19.59, SD = 1.75). A majority of the sample identified as White (n = 112; 59.9%), 22 identified (11.8%) as Black, 39 (20.9%) identified as Hispanic, 9 (4.8%) identified as Asian, and 5 (2.7%) as “Other.”

All study procedures were approved by the same institutional review board mentioned in Study 1. Informed consent was obtained prior to any study involvement. Participants completed an online battery of questionnaires on a laboratory computer in addition to an in-person appearance-related stressor task. All study participants were debriefed about the study purpose upon completion of the study and were compensated with course credit for their participation.

Measures

Self-Report Measures

Participants were administered the 10-item BDD-YBOCS-SR (see Study 1 for measure description) as well as the Depression, Anxiety, Stress Scale-21 (DASS-21; Lovibond & Lovibond, 1995). The DASS-21 is a self-report measure of depression, anxiety, and stress in adults. The DASS-21 consists of 21 items that are rated on a scale from 0 (Did not apply to me at all) to 3 (Applied to me very much or most of the time) indicating how much a statement applied to the individual. The DASS-21 has demonstrated excellent psychometric properties in community and clinical samples (Antony et al., 1998). In the present sample, the DASS-21 demonstrated excellent internal consistency in the present sample (α = .93).

In Vivo Stressor (Picture) Task

After participants completed self-report questionnaires, a trained research assistant administered an in-person stressor task designed to assess BDD-related concerns (Summers & Cougle, 2016). In this task, participants were given the following instructions:

In this next part of the study, we will be taking a few pictures. The purpose of this is to get an idea of your comfort level, so please pay attention to your emotions during this task. We will first take a picture of your entire body from the front, then a picture from the back, and finally a picture of your face from the shoulders up.

Once this prompt was given, participants were asked to rate their current fear and urge to check appearance on a 0 (Not at all) to 10 (Extremely) scale prior to the picture, with higher numbers reflecting greater reactivity to the task. Following the three pictures, participants were asked to rate their peak fear during the task on the same 0 to 10 scale. All participants were debriefed on the true nature of the task, and the pictures were immediately deleted.

Results

Reliability Analysis

The internal consistency of the BDD-YBOCS-SR in the present sample was good (α = .86; women α = .87, men α = .83). The internal consistencies of the three factors of the BDD-YBOCS-SR ranged from adequate to good (i.e., Factor 1 α = .73; Factor 2 α = .80; Factor 3 α = .72)

Convergent Validity Analyses and Associations With Appearance-Related In Vivo Task

Zero-order correlations and descriptive statistics can be found in Table 3. There were no missing patterns of data. The total score of the BDD-YBOCS-SR and the three-factor scores were found to be significantly correlated with total DASS-21 scores (i.e., depression, anxiety, and stress) as well as participants’ reactivity to the picture task (i.e., ratings of pre-task fear, pre-task urge to check appearance, and peak fear experienced during the task).

Table 3.

Study 2—Zero-Order Correlations (N = 187).

Variables	M	SD	1	2	3	4	5	6	7
1. BDD-YBOCS-SR	8.32	5.70	—
2. BDD-YBOCS-F1	2.99	1.96	.84*	—
3. BDD-YBOCS-F2	2.30	2.10	.85*	.63*	—
4. BDD-YBOCS-F1	3.03	2.63	.87*	.57*	.57*	—
5. DASS-21	9.15	9.53	.44*	.31*	.51*	.31*	—
6. Pre-task fear	1.95	1.70	.34*	.35*	.36*	.18^†	.52*	—
7. Urge to check appearance	3.39	2.63	.55*	.52*	.48*	.42*	.49*	.58*	—
8. Post-task fear	2.60	2.28	.47*	.46*	.45*	.33*	.50*	.72*	.66*

Note. M = mean; SD = standard deviation; BDD-YBOCS-SR = Yale–Brown Obsessive Compulsive Scale modified for Body Dysmorphic Disorder-Self Report; BDD-YBOCS-F1 = Factor 1 (time/interference BDD thoughts and compulsions); BDD-YBOCS-F2 = Factor 2 (distress and control of BDD thoughts); BDD-YBOCS-F3 = Factor 3 (distress and control of BDD activities); DASS-21 = Depression, Anxiety, Stress Scale-21.

†

p < .01. * p <.001.

To further determine the convergent validity of the BDD-YBOCS-SR, we conducted linear regression analyses to determine whether the BDD-YBOCS-SR remained associated with the in vivo task responses when covarying for depression, anxiety, and stress (DASS-21). Scores on the BDD-YBOCS-SR were significantly associated with pre-task urge to check appearance (b = 0.22, SE = 0.03, β = .45, p < .001, pr² = 0.22) when covarying for depression, anxiety, and stress (b = 0.08, SE = 0.02, β = .29, p < .001, pr² = 0.10). Scores on the BDD-YBOCS-SR were also associated with peak fear experienced during the task (b = 0.14, SE = 0.03, β = .34, p < .001, pr² = 0.13) when covarying for depression, anxiety, and stress (b = 0.09, SE = 0.02, β = .35, p < .001, pr² = 0.12). However, the scores on the BDD-YBOCS-SR were no longer significantly associated with pre-task fear (b = 0.05, SE = 0.02, β = .15, p = .06, pr² = 0.03) when covarying for depression, anxiety, and stress (b = 0.08, SE = 0.01, β = .45, p < .001, pr² = 0.19).

We also examined the association between the 3 factors of the BDD-YBOCS-SR and these outcomes. The patterns were similar, except that Factor 1 (overall BDD interference) was significantly associated with pre-task fear (b = 0.22, SE = 0.06, β = .25, p < .001, pr² = 0.08) when covarying for depression, anxiety, and stress (b = 0.08, SE = 0.01, β = .44, p < .001, pr² = 0.21).

Study 3

In Study 3, we sought to compare the scores on the BDD-YBOCS-SR between a clinical sample of individuals with BDD (N = 50) and a nonpsychiatric “healthy” control sample (N = 51). In addition, we examined the association between the BDD-YBOCS-SR and the rater-administered BDD-YBOCS in the clinical sample (i.e., clinical sample was administered both versions). Finally, the clinical sample data in the current study was from a larger internet-based treatment trial for BDD, which further afforded us the ability to test the BDD-YBOCS-SR’s sensitivity to change over time (i.e., from pre- to post-treatment).

Method

Participants and Procedures

The clinical sample consisted of 50 participants diagnosed with BDD who consented to a treatment trial where they were either randomized to online interpretation bias modification (IBM) or progressive muscle relaxation (PMR; see Wilver & Cougle, 2019 for a more thorough overview of study procedures). Both interventions lasted for a period of 1 month, and data from pre- and post-treatment visits were examined. Some of the participants were recruited from the psychology subject pool (similar to procedures presented in Studies 1 and 2); participants were also recruited from the community through flyers and Craigslist postings. Eligibility criteria for the study included the following: (a) between the ages of 18 and 65 years old, (b) proficient in English, (c) diagnosis of clinical BDD as assessed by the study principal investigator via the BDD-module of the Semi-structured Clinical Interview for the DSM-5 (SCID-5; First et al., 2015) and a score of 20 or greater on the rater-administered BDD-YBOCS. Exclusion criteria included having a lifetime history of psychotic symptoms, bipolar disorder, borderline personality disorder, active alcohol or substance use disorder, unstable psychotropic medication status, concurrent psychotherapy for BDD, or significant suicidality. All study procedures were approved by the same university institutional review board mentioned in Studies 1 and 2; informed consent was obtained from all participants prior to conducting the clinical interview. A majority of the sample identified as women (n = 42; 84.0%), and one individual (2.0%) identified as transgender. Participants’ ages ranged from 18 to 53 years (M = 28.52, SD = 9.32). A total of 29 (58.0%) individuals identified as White/Caucasian, 6 (12.0%) as Hispanic, 7 (14.0%) as Black, 5 (10.0%) as Asian or Pacific Islander, and 3 (6.0%) identified as “Other.”

The non-psychiatric “healthy” control sample (n = 51) was recruited from a larger study investigating correlates of general mood and anxiety symptoms in an undergraduate sample. Participants were designated as “healthy” if they did not screen positive for BDD (assessed via the BDD-module of the SCID-5; First et al., 2015) or any other psychiatric disorder captured in the Mini-International Neuropsychiatric Interview (Sheehan et al., 2006). Informed consent was obtained from all study participants, and all study procedures were approved by the intuitional review board at the same southeastern university where the clinical sample was recruited. A majority of the sample identified as women (n = 36; 70.6%). The age of the sample ranged from 18 to 30 years (M = 19.75, SD = 2.00). With respect to race and ethnicity, the sample predominantly identified as White (n = 31; 60.8%), 10 (19.6%) identified as Hispanic, 4 (7.8%) identified as Black, 5 (9.8%) identified as Asian or Pacific Islander, and 1 individual identified as “Other.”

Measures

Clinical Interviews

The rater-administered BDD-YBOCS was used to measure BDD symptom severity in the clinical sample and obtain diagnostic criteria to meet study eligibility (Phillips et al., 1997). All interviews were administered by an advanced graduate student who had undergone extensive training to implement it appropriately; the interviewer was blinded to treatment condition of participants. The semi-structured interview consisted of 12 questions that assess past-week BDD symptoms severity, though, similar to the self-report BDD-YBOCS, only the first 10 items were used for the present analyses. The internal consistency of the interview was adequate in the present sample (α = .71). The rater-administered BDD-YBOCS was only administered to the clinical sample and not the healthy control sample.

Self-Report Measures

Similar to both Study 1 and Study 2, the 10-item self-report version of the BDD-YBOCS (i.e., the BDD-YBOCS-SR) was administered to both the clinical and the healthy samples.

Beck Depression Inventory-II

The Beck Depression Inventory-II (BDI-II) is a widely used self-report measure of past-week depressive symptoms consisting of 21 items (Beck et al., 1996). The internal consistency of the BDI-II was excellent in the total sample (α = .93); broken down by group, it was good for the healthy group (α = .80) and excellent for the clinical sample (α = .95).

Beck Anxiety Inventory (BAI)

The BAI is a widely used measure of past-week general anxiety consisting of 21 items (Beck et al., 1988). The internal consistency of the BAI was excellent in the total sample (α = .95), adequate for the healthy sample (α = .74), and excellent for the clinical sample (α = .93).

Results

Reliability Analyses

The internal consistency of the BDD-YBOCS-SR was adequate for the healthy group (α = .79). The pretreatment internal consistency for the clinical group was adequate (α = .76), and the posttreatment internal consistency was excellent (α = .92).

Group Comparisons

Descriptive statistics for both samples can be found in Table 4. One-way analysis of variance (ANOVA) revealed that scores on the BDD-YBOCS-SR were found to be significantly higher in the BDD group compared with the healthy control group, F (1, 99) = 420.64, p < .001, η² = .81. Group differences on the BDD-YBOCS-SR remained when controlling for depression and general anxiety, F (1, 76) = 177.02, p < .001, η_p² = .70.

Table 4

Studies 3—Means and Standard Deviations of Self-Report Measures (N = 101).

Variable	Study 3 Healthy sample (n = 51)		Study 3 Clinical sample (n = 50)
Variable	M	SD	M	SD
BDD-YBOCS-SR	6.61	4.86	24.94	4.08
BDD-YBOCS-RA			29.36	4.41
BDI-II	4.26	4.62	20.84	12.66
BAI	4.42	4.64	17.29	13.57
Post-treatment
BDD-YBOCS-SR			19.16	8.33
BDD-YBOCS-RA			18.61	8.40
BDI-II			16.22	13.90
BAI			14.35	14.1

Note. BDD-YBOCS-SR = Yale–Brown Obsessive Compulsive Scale modified for Body Dysmorphic Disorder-Self Report; BDD-YBOCS-RA = 10-item Yale–Brown Obsessive Compulsive Scale modified for Body Dysmorphic Disorder-Rater-Administered; BDI-II = Beck Depression Inventory; BAI = Beck Anxiety Inventory.

Convergence Between Self-Report and Interview Measures and Sensitivity to Treatment

The next analyses were conducted among only the clinical BDD sample who completed both versions of the BDD-YBOCS and also underwent internet-based treatment. Importantly, one individual did not complete the post-treatment evaluation and was not included in subsequent analyses. The total score of the 10-item BDD-YBOCS-SR was significantly correlated with first 10 items of the rater-administered BDD-YBOCS at baseline (r = .78, p <.001) and post-treatment (r = .93, p <.001).

Repeated measures ANOVAs were conducted to assess sensitivity to treatment as measured by the BDD-YBOCS-SR and the rater-administered BDD-YBOCS; again, only the first 10 items were used in analyses. Mean scores were significantly different from baseline to post-treatment for both the BDD-YBOCS-SR, F(1, 48) = 95.67, p < .001, η_p² = .66, η²_G = .36, and the rater-administered BDD-YBOCS, F(1, 48) = 80.26, p < .001, η_p² = .63, η²_G = .38. These findings highlight how the BDD-YBOCS-SR demonstrates similar sensitivity to treatment as the rater-administered BDD-YBOCS.

Next, we sought to examine whether either BDD-YBOCS measure detected unique change in BDD symptoms from the other measure. We conducted repeated measures ANCOVAs while also covarying for pre-post change in the alternate BDD-YBOCS measure (e.g., evaluated change in self-report BDD-YBOCS while covarying for clinical administered BDD-YBOCS change). For the self-report BDD-YBOCS, the difference between pre- and post-treatment scores were no longer significant, F(1, 47) = 2.22, p = .143, η_p² = .05. For the rater-administered YBOCS, the pre- to post-treatment differences were also no longer significant, F(1, 47) = 1.18, p = .283, η_p² = .02. These findings indicate the measures assessed overlapping symptomatology.

Discussion

The findings of the present investigation provide initial evidence in support of the reliability and validity of the 10-item self-report version of the BDD-YBOCS (i.e., the BDD-YBOCS-SR). Although the factor structure of the BDD-YBOCS-SR was found to reasonably map on to the two-factor structure of the traditional BDD-YBOCS-RA (Phillips et al., 2014), several of the factor loadings were low. Utilizing an EFA-to-CFA approach yielded a three-factor structure of the BDD-YBOCS-SR with one factor being related to time and interference related to BDD thoughts and compulsions, another being related to distress and control over BDD-related thoughts, and a third that was related to distress and control over BDD-related compulsions. The BDD-YBOCS-SR evidenced convergent validity with a commonly used measure of appearance anxiety. This association was found to be statistically stronger than the relationship between the BDD-YBOCS-SR and measures of depression, drive for thinness, and bulimia providing preliminary evidence of divergent validity.

The BDD-YBOCS-SR was further related to reactivity in response to an in vivo picture task designed to evoke and measure BDD-related appearance concerns (i.e., strong positive associations with participants’ ratings of pre-task fear, pre-task urge to check the appearance, and peak fear experienced during the task). Aside from pre-task fear, these relationships largely held even after covarying for general depression, anxiety, and stress. This finding may be explained by pre-task fear being more related to general anticipatory anxiety rather than specific BDD symptoms. Although this hypothesis would need to be tested further to truly determine the nature of these relationships, this was partly evidenced by the finding that Factor 1(i.e., time and interference related to BDD thoughts and compulsions) was significantly related to pre-task fear. This multimethod approach provides further evidence of convergent validity beyond similar self-report measures.

When administered to a clinical sample of individuals with BDD and nonpsychiatric “healthy” controls, group comparisons revealed that the clinical sample scored significantly higher on the BDD-YBOCS-SR, with large effect sizes. Group differences remained after covarying for general anxiety and depression. These findings further demonstrate the validity of the BDD-YBOCS-SR in detecting and measuring BDD severity.

We also compared the BDD-YBOCS-SR to the rater-administered BDD-YBOCS in the clinical sample. The self-report and rater-administered versions of the measure were highly correlated at baseline and after a course of internet-delivered treatment, demonstrating convergence between modes of administration and equivalent sensitivity to change in symptoms over time. In addition, the internal consistency of the BDD-YBOCS-SR was evaluated in each study and was found to be adequate to excellent across the three studies demonstrating the reliability of the measure in both college and clinical samples. Collectively, these findings suggest that the BDD-YBOCS-SR could offer an efficient, cost-effective means of evaluating BDD symptoms and treatment response in research or clinical settings when raters are not available or practical to use, without sacrificing reliability or validity.

Despite these promising findings, it is important to note the limitations of the present investigation. First, the age across all three samples was relatively young. With appearance concerns being identified across the lifespan (Carrard et al., 2021), it is imperative that future research seek to evaluate the measure in a more age-dispersed sample to examine the utility of the self-report version in middle-aged and older adults. Second, most of the participants in these studies identified as women which could limit the generalizability of the observed results in men or trans individuals. Though we have no clinical or theoretical reason to expect symptom severity patterns to differ by gender, future studies could seek to observe factor structure and gender differences in more diverse samples. Third, despite initial analyses demonstrating sensitivity, the present investigation was unable to determine the BDD-YBOCS-SR stability over time. Fourth, despite providing preliminary evidence for the divergent validity of the BDD-YBOCS-SR, future research should seek to further investigate divergent validity outside depression and eating disorder symptoms. Fifth, the present study was unable to determine a cut score for the BDD-YBOCS-SR. While prior studies have utilized a cut score of 16 or higher, further work is needed to empirically establish a cutoff score that can serve as a clinically meaningful change value (i.e., point on scale where the individual is more likely to fall into the nonclinical score distribution rather than the clinical score distribution). Sixth, while the present study was able to confirm the factor structure of the BDD-YBCOS-SR, we did so in a community sample. Future research should further investigate the factor structure in a clinical sample. Seventh, the BDD-YBOCS-SR may be limited in its instructions. Although each question offers relatively clear prompts for what it is meant to capture, the measure does not include psychoeducational background about BDD and its features in the formal instructions, which may leave room for interpretive error. In Study 3, the correlations between the self-report and rater version of the BDD-YBOCS were lower at baseline than post-treatment, suggesting possible variability in how participants initially conceptualized items. It is also possible that this difference could be related to insight, as participants may not have been used to reflecting on the impact of symptoms in this way prior to enrolling in the study but learned to better attend to this over time. Future research should also seek to explore Item’s 11 (Insight) and 12 (Avoidance) of the BDD-YBOCS. While the present study was able to evaluate at the 10-item BDD-YBOCS-SR, further research may seek to determine if the 12-item version may be appropriate for use in self-report formats. Future research could investigate whether individuals may in fact be better able to rate insight and avoidance than we would expect. While these 2 items may not significantly change the evidence that is provided in this investigation, the inclusion of these 2 items could provide further insight into BDD pathology and how treatment can affect BDD-related insight and avoidance. Similarly, future use of the BDD-YBOCS-SR may benefit from including more detailed instructions and information on appearance concerns to “set the stage” before individual items are shown. For instance, researchers might consider providing a brief orientation to the spectrum of appearance concerns at the beginning of the measure, illustrating how type of concerns common in BDD (or the impact of these concerns) differ from normative appearance concerns or those common in eating disorders. Such an approach might leave less room for interpretive error and enhance the likelihood of only target symptoms being assessed.

While the rater-administered BDD-YBOCS is the gold standard measurement of BDD symptom severity, the BDD-YBOCS-SR provides an important version of the measure that could be utilized in scenarios where the rater-administered version may not be possible to administer. Specifically, the BDD-YBOCS-SR could be used in treatment trials or clinical practice to measure weekly or daily changes in symptoms or online studies where a rater would be impractical or unavailable. While interview-administered measures are often considered superior in terms of consistency and accuracy when compared to self-report measures, these measures could also be subject to rater biases. The rater may develop an expectancy bias or require periodic recalibration due to “rater drift” over time; while interviewees may alter their report due to shame or desire to meet an interviewer’s expectations (Cook, 2010; Hartman et al., 2002). In addition, the BDD-YBOCS-SR could be used in medical settings with regard to measurement-based care (i.e., routine objective assessment of clinical outcomes; Fortney et al., 2017). BDD is rarely screened for in medical and clinical settings (Phillips, 2006), and the BDD-YBOCS-SR could further measurement-based care initiatives and help identify individuals with BDD who are likely to benefit from treatment. While the BDD-YBOCS-SR provides unique utility as a self-report measure and addresses limitations of rater-administered measures, this does not mean that it subsumes the need for the rater-administered BDD-YBOCS. While the BDD-YBOCS-SR may be better used to measure symptom change in short periods or in online studies, the rater-administered BDD-YBOCS may be better utilized in large treatment development trials to reduce bias in reporting across long timeframes or in studies or cases where an individual with low-insight may require a rater to increase accurate reporting. Regardless, continued implementation and comparisons of both versions of the BDD-YBOCS will prove to be valuable in further evaluating and addressing BDD.

In addition, while the total score of the BDD-YBOCS-SR may provide the most utility in measuring BDD symptom severity, it is important to consider the three factors identified in the present study in future research. The use of these three factors as subscales could potentially help better understand mechanisms that maintain and contribute to BDD. For example, a treatment study utilizing the BDD-YBOCS-SR may be able identify that a specific portion of a treatment affects control over compulsions before control over thoughts. Further work is necessary to determine the utility of these three factors as meaningful subscales, but it is important to consider that these three factors are highly correlated. Obsessive thoughts and compulsions are highly related within BDD.

Overall, the present investigation provides support for the use of the BDD-YBOCS-SR. The measure demonstrated strong reliability, convergent and divergent validity, and sensitivity to treatment. In addition, with the inherent limitations of a rater-administered measure, the BDD-YBOCS-SR could continue to prove to be valuable measure of BDD symptom severity in future research studies. The BDD-YBOCS-SR could also prove to be a vital tool in clinical settings to quickly screen for BDD symptoms and their severity.

Supplemental Material

sj-docx-1-asm-10.1177_10731911221124341 – Supplemental material for Reliability and Validity of the Self-Report Version of the Yale-Brown Obsessive-Compulsive Scale Modified for Body Dysmorphic Disorder

Supplemental material, sj-docx-1-asm-10.1177_10731911221124341 for Reliability and Validity of the Self-Report Version of the Yale-Brown Obsessive-Compulsive Scale Modified for Body Dysmorphic Disorder by Tapan A. Patel, Berta J. Summers, Natalie L. Wilver and Jesse R. Cougle in Assessment

Footnotes

Appendix

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Tapan A. Patel

Supplemental Material

Supplemental material for this article is available online.

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