Effects of Appearance Preoccupation and Safety Behaviors in Body Dysmorphic Disorder: An Ecological Momentary Assessment Study

• We assessed relations of daily appearance-related preoccupation and safety behavior. • Adults with body dysmorphic disorder (BDD) and healthy controls were compared. • higher body dissatisfaction and conviction following appearance-related processes. • BDD participants endorsed higher negative affect following preoccupation and gazing. • Results for positive affect & delayed effects (≥ 30 min later) were not significant. Body dysmorphic disorder (BDD) is characterized by excessive appearance-related preoccupation and safety behaviors. Cognitive-behavioral models suggest that these processes reinforce dysfunctional beliefs about appearance, thus maintaining BDD symptoms. To date, few experimental and cross-sectional studies suggest a potential etiological role of these mechanisms; however, they remain unstudied within an externally valid, daily life setting. In this study, we examined the functional relationships of appearance-related processes in daily life. Specifically, we investigated the effects of appearance-related preoccupation and safety behaviors on body dissatisfaction, conviction about perceived appearance flaws and affect using ecological momentary assessment. Thirty individuals with BDD and 30 psychiatrically healthy controls (HC) completed smartphone-based state measures including two event-based prompts (i.e., matutinal and nightly assessments) and up to eight random prompts daily over the course of six days. Out of 3075 assessments, 875 assessments captured self-reports right after engaging in appearance-related preoccupation and safety behaviors. Multilevel regression analyses indicated immediate increases in body dissatisfaction and appearance-related conviction in individuals with BDD after engaging in any appearance-related process. Following preoccupation and gazing, individuals with BDD reported higher negative affect. HC showed increased body dissatisfaction and conviction after engaging in any appearance-related process, but no concurrent changes in negative affect. Associations for positive affect and delayed effects across prompts were non-significant. Overall, these findings demonstrate model-congruent negative effects of appearance-related preoccupation, gazing and other safety behaviors for BDD symptom maintenance, highlighting needs to carefully monitor and address these factors in treatment.