Journal of Psychosomatic Research 70 (2011) 286–293

Treatment utilization and barriers to treatment engagement among peoplewith body dysmorphic symptoms☆

Luana Marquesa,⁎, Hilary M. Weingardena,b, Nicole J. LeBlanca,b, Sabine Wilhelma

aDepartment of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USAbTufts University, Medford, MA, USA

Received 3 May 2010; received in revised form 27 September 2010; accepted 1 October 2010

Abstract

Objectives: Body dysmorphic disorder (BDD) is characterizedby an excessive preoccupation with an imagined or minorappearance flaw. Many aspects of BDD remain unknown, suchas rates of treatment utilization, types of treatment sought, andbarriers to treatment. The present study sought to examine ratesand patterns of treatment utilization as well as barriers to treatmentamong individuals with body dysmorphic symptoms. Methods:The present study consists of 401 individuals with symptomsconsistent with a diagnosis of BDD who completed self-reportedmeasures of treatment utilization and barriers to treatment in aninternet survey. Results: Consistent with past research, results

☆ Disclosures: Luana Marques, Ph.D.: past 3 years: NIMH (salary andresearch funding). Hilary Weingarden: no disclosures. Nicole LeBlanc: nodisclosures. Sabine Wilhelm, Ph.D.: past 3 years: NIMH (salary andresearch funding), Tourette Syndrome Association (salary and researchfunding), Obsessive Compulsive Foundation (salary and research funding),FDA (salary and research funding), Forest Laboratories (medication forNIMH-funded study), New Harbinger Publications (book royalties), OxfordUniversity Press (book royalties), Guilford Press (potential future bookroyalties), speaking honoraria from various academic institutions.

⁎ Corresponding author. Department of Psychiatry, MassachusettsGeneral Hospital, 1 Bowdoin Street, Boston, MA 02114, USA. Tel.: +1617 726 0776; fax: +1 617 643 0730.

E-mail address: lmarques@partners.org (L. Marques).

0022-3999/10/$ – see front matter © 2011 Elsevier Inc. All rights reserved.doi:10.1016/j.jpsychores.2010.10.002

showed that individuals with probable BDD reported seekingnon-mental health treatments for BDD (e.g., plastic surgery).Additionally, an examination of treatment barriers demonstratedsignificant barriers for the sample for the three domains examined:logistic and financial; stigma, shame, and discrimination; andtreatment skepticism. Secondary analyses revealed a differentialendorsement of treatment barriers across ethnic groups for all threebarrier domains. Conclusion: These data suggest that BDD is stillan underrecognized disorder with marked barriers to treatment.Increased education and dissemination efforts are warranted.© 2011 Elsevier Inc. All rights reserved.

Keywords: Body dysmorphic disorder (BDD); Barriers to treatment; Treatment utilization

Introduction

Body dysmorphic disorder (BDD) is characterized by anexcessive, often delusional preoccupation with an imagined orminor appearance flaw. It is a relatively common disorder,with lifetime prevalence rates in community settings of appro-ximately 0.7% to 2.4% [1–4]. BDD typically has an onset in

adolescence and a chronic course [5]. The disorder is oftenassociated with significant psychosocial impairment;ranging from moderate impairment and/or distress to some-times severe interference that leaves sufferers housebound orunable to work [6,7]. Individuals with BDD also suffer fromhigh rates of lifetime suicidal ideation (78%), suicide attempts(27.5%; [8]), and yearly completed suicide (0.3%; [9]).

Despite the substantial psychosocial impact of BDD, itremains an underrecognized and understudied disorder. Assuch, rates and patterns of psychological treatment utilizationin BDD are not known. However, past research hasexamined which treatments are most effective. The literaturehas demonstrated that cognitive behavioral therapy (CBT)and selective serotonin reuptake inhibitors (SSRIs) are themost effective psychotherapeutic and psychopharmacologictreatments for BDD, respectively [10,11].

There is also a lack of data about barriers to seekingtreatment for individuals with BDD.While treatment barriersin BDD are currently unknown, it is likely that barriers to

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treatment for other psychological illnesses also inhibitindividuals with BDD. Treatment barriers common tomany psychological illnesses include logistic and financialbarriers [12–16], stigma, shame and discrimination barriers[16–18], and skepticism or negative perceptions of treatment[19]. Gaining an understanding of how barriers influencetreatment utilization in BDD is crucial to targeting barriersand improving treatment dissemination and access.

Considering the lack of data on treatment utilization andbarriers to treatment in BDD, there is a need to empiricallyexplore these domains. Such research has the potential toimprove treatment dissemination and to take a primary step inaddressing the economic consequences of untreated mentalillness. Research has demonstrated that societal costs of notproviding treatment to individuals with mental disorders areextensive and exceed the costs of providing treatment [20].These costs may be particularly relevant to BDD, as manysufferers are housebound, unemployed, and receiving disabi-lity [6]. Additional costs unique to untreated BDD includecosmetic surgeries, unnecessary dermatological appoint-ments, and money spent on makeup, wigs, and other beautyproducts used to disguise perceived appearance flaws [6].

The current study was a cross-sectional internet study ofindividuals with symptoms consistent with a diagnosis ofBDD. It was designed to address the lack of researchexamining treatment utilization and barriers to treatment inindividuals with body dysmorphic symptoms. First, thecurrent study investigated participants' rates and patterns oftreatment utilization with a specific focus on understandingthe utilization of empirically supported treatments. Second,perceived barriers to treatment were examined in an attemptto understand rates of treatment utilization in the sample andto guide future dissemination efforts.

Finally, as a secondary objective of the current study,ethnic differences in barriers to treatment were examined. Thisaim was included in the current study because the broaderpsychological literature has shown that ethnic minorities faceadditional barriers to treatment when compared to Caucasians[17,21]. These barriers likely impact minority patients withBDD as well. For example, financial barriers [13,20] as wellas fear of discrimination have been documented to beespecially important barriers for ethnic minorities [21–23].In addition, stigma is a particularly influential barrier totreatment for certain ethnic groups such as Latinos, for whomnegative cultural beliefs exist about taking psychotropicmedications [23,24]. Ultimately, gaining an understanding ofhow barriers to treatment influence ethnic minorities withBDD is crucial to targeting barriers and improving treatmentdissemination and access for patients with this disorder.

Method

Participants

The institutional review board at the MassachusettsGeneral Hospital reviewed and approved all recruitment

and study procedures. Participants for the present studywere recruited through advertisements posted in onlineBDD forums, on BDD clinic websites, and around theBoston area.

The online survey was active between November 2008and January 2009, during which time a total of 782 responseswere collected. Duplicate and incomplete responses wereremoved. Participants were only included in subsequentanalyses if they met inclusion criteria for the current study.To be included, participants must have been (1) at least18 years of age, (2) proficient in English, (3) diagnosedor self-diagnosed with BDD, which was assessed using acutoff score of greater than or equal to 16 on the 10-itemYale-Brown Obsessive Compulsive Scale Modified forBDD (BDD-YBOCS), as well as by including onlyanswers consistent with a diagnosis of BDD on the BodyDysmorphic Disorder Questionnaire (BDDQ). Exclusioncriteria eliminated participants whose primary concernswere weight concern (assessed by the BDDQ) in orderto exclude participants with a probable primary diagnosisof an eating disorder. A total of 401 participants metinclusion criteria and comprised the final sample used fordata analysis.

Measures

All measures were presented in self-report format andwere answered by participants via an online survey.

Measures of BDD

The BDD-YBOCS [25] was used to measure BDDsymptom severity over the past week. Higher scores indicatemore severe symptoms. The BDD-YBOCS assesses obses-sions and compulsions related to body image concerns, and itclosely mirrors the structure of the Y-BOCS [26], which isused to measure the severity of obsessions and compulsionsin obsessive–compulsive disorder (OCD). Similar to whathas been previously published for OCD [27], the presentstudy used a 10-item version of the BDD-YBOCS, as themore common 12-item version includes a measure of insight,a construct that is difficult to assess through self-report. Inaddition, minor edits were made to the wording of theindividual 10-item BDD-YBOCS questions to ensure thatthey were appropriate for self-report. The 12-item BDD-YBOCS has good interrater and test–retest reliability (ICCfor total score = 0.99 and 0.88, respectively), internalconsistency (α= .80), convergent validity (r= .55 with theCGI), and sensitivity to change with treatment [25]. The10-item version has comparable reliability, factor structure,convergent and discriminant validity, and sensitivity tochange [25]. In our study, the BDD-YBOCS had acceptablereliability (Cronbach's α= .76).

The BDDQ [6] is a self-report measure used to assesscurrent clinical BDD. The questionnaire asked (1) whetherparticipants are very worried about how they look, think

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about their appearance problems a lot, and wish they couldthink about the problems less; (2) whether their mainappearance concern is that they are not thin enough or mightbecome too fat; (3) whether appearance concerns haveaffected their life by often upsetting them a lot, often gettingin the way of doing things with friends or dating, causingproblems with school or work, or causing them to avoidactivities; and (4) how much time is usually spent per dayfocusing on the appearance concerns. Participants whoindicated on Question 2 that primary concerns were weightconcerns were excluded from analyses. The BDDQ has beenshown to have excellent sensitivity (100%) and specificity(89%) in inpatient psychiatric hospitals [6].

Barriers to treatment measures

Treatment History QuestionnaireThe Treatment History Questionnaire was designed for

the present study to assess participants' lifetime treatmentutilization for BDD. The items in this questionnaire weremodeled after items used in previous studies that haveexamined similar treatment history variables [28]. Questionsregarding treatment providers included “Have you ever inyour lifetime seen any of the following professionals for yourBDD symptoms?” The use of psychological treatments wasmeasured with the question: “Have you ever received any ofthe following treatments for your BDD symptoms?” Andpsychopharmacological treatment use was measured byasking participants to mark any medications that they hadtaken for past or present BDD, OCD, or another psychiatricdisorder. Comprehensive answer choices were provided witheach question.

Barriers to Treatment QuestionnaireThe Barriers to Treatment Questionnaire (BTQ) was used

to measure participants' perceived barriers to treatment-seeking. The questionnaire was created for the purpose of thepresent study and was based on variables examined in thebroader barriers to treatment literature [28]. The BTQassessed treatment barriers in the following domains: logisticand financial; stigma, shame, and discrimination; andtreatment perception and satisfaction. Participants werepresented with a list of concerns and asked (yes/no) whetherthey influenced their decision to avoid or delay treatmentutilization (see Table 2 for individual items). Results areshown as the frequency of participants who endorsed “yes”for each barrier.

Procedure

Data collectionParticipants completed all measures in the form of a

survey designed on surveymonkey.com [29]. Interestedparticipants were guided to the online survey via a webaddress posted in study advertisements. Participants werefirst directed to the informed consent page explaining the

voluntary and confidential nature of the study, and they wererequired to read and mark agreement in order to continue.The survey then directed participants through a series ofdemographic questions and measures aimed to gather awide range of data on body dysmorphic symptoms andseverity, treatment history, and barriers to treatment. Parti-cipants had the option of skipping any questions. Subjectsreceived $10 electronic gift certificates for their involve-ment in the study.

Analytical strategy and power analysis

SPSS version 17.0 was used for data analyses. Theindividual barriers items from the BTQ were categorized into(1) logistic and financial barriers; (2) stigma, shame, anddiscrimination barriers; and (3) treatment satisfaction andperception barriers (see Table 3 for item categorization). Thismodel was consistent with past research that has examinedbarriers to mental health care at three levels: system, patient,and provider [30].

A composite score was then calculated for eachparticipant in each of the three barriers to treatmentcategories. Analysis of covariance was used to determinethe effect of ethnicity on participants' endorsed barriers totreatment in each category. Income and insurance statuswere factored into each model as covariates in order toensure that group differences in socioeconomic statusand ability to pay for medical care did not account forthe findings.

Results

Description of sample

The sample ranged in age from 18 to 62 years, with amean (S.D.) age of 31.57 (9.79) years. For a demographicdescription of the sample, see Table 1.

The overall sample mean (S.D.) for the BDD-YBOCSwas 22.06 (4.25), a score that falls within the range ofmoderately severe BDD symptoms. There was no signifi-cant difference between ethnic groups with respect toseverity of body image concerns [F(4,396) = 2.30, P=n.s.],suggesting that body image concerns were equally impairingacross ethnic groups in the current sample. As such, BDDsymptom severity was not entered as a covariate insubsequent analyses.

Treatment utilization

Lifetime rates of treatment utilization are presented inTable 2. Participants most frequently sought help for bodyimage concerns from general practitioners (37.2%), followedby psychiatrists (30.5%) and psychologists (29.5%). Notsurprisingly, there were similar rates of reported treatmentutilization from medical professionals specializing in

Table 2Frequencies of treatment utilized for body dysmorphic symptoms

Treatment utilization % (n)

Professionals sought for treatmentGeneral Practitioner 37.2 (124)Psychiatrist 30.5 (101)Psychologist 29.5 (98)Dermatologist 24.6 (82)Dentist (for cosmetic procedures) 19.9 (66)Plastic surgeon 13.8 (46)Religious/spiritual advisor (e.g., minister,priest, rabbi)

11.3 (37)

Other mental health professional (e.g., nurse) 10.9 (36)Social worker 10.6 (35)Para-professionals (e.g., laser hair removal) 8.5 (28)Other healer (e.g., herbalist, chiropractor,eastern medicine)

7.4 (24)

PsychotherapyTalk therapy 35.1 (117)CBT 17.4 (58)EMDR 8.4 (28)Other 5.4 (17)

PsychopharmacologySSRIs a 34.4 (138)Anxiolytics b 14.2 (57)Antipsychotics c 11.7 (47)Clomipramine 5.5 (22)Other 5.0 (20)

EMDR, eye movement desensitization and reprocessing.a Including fluoxetine (Prozac), sertraline (Zoloft), escitalopram (Lexa-

pro), citalopram (Celexa), paroxetine (Paxil), and fluvoxamine (Luvox).b Anxiolytics include lorazepam (Ativan), diazepam (Valium), and

clonazepam (Klonopin).c Antipsychotics include quetiapine (Seroquel), aripiprazole (Abilify),

and olanzapine (Zyprexa).

Table 1Demographic characteristics of sample

n %

EthnicityCaucasian/white 293 73.1Latino/Latina 25 6.2African American/black 17 4.2Asian 49 12.2Multiracial/other 17 4.2Marital statusSingle 152 37.9Dating/cohabitating 63 15.7Married 158 39.4Separated/divorced 19 4.7Widowed 4 1.0Employment statusFull-time 174 43.4Part-time 56 14.0Unemployed 29 7.2Housewife 41 10.2On disability 22 5.5Student 75 18.7Highest educationSecondary school 50 12.5Some college 116 28.92-year college 39 9.74-year college 125 31.2Some graduate 23 5.7Advanced/graduate 48 11.9Total family income/yearBelow $10,000 17 4.2$10,000–19,999 31 7.7$20,000–29,999 53 13.2$30,000–39,999 59 14.7$40,000–49,999 77 19.2$50,000–59,999 48 12.0$60,000 or greater 114 28.4

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aesthetic treatments, such as dermatologists (24.6%),dentists (19.9%), and plastic surgeons (13.8%). These dataare consistent with past research documenting that BDDpatients often seek such nonpsychiatric treatments fortheir concerns [31].

With respect to psychological care, most participantsreported receiving talk therapy (35.1%), with only a smallpercentage of participants receiving empirically supportedpsychotherapy (i.e., CBT; 17.4%). Finally, the mostcommonly prescribed psychotropic medications wereSSRIs (34.4%).

Barriers to treatment seeking

Participants endorsed numerous and varied barriers totreatment (see Table 3). Shame (55.6%) and a desire tohandle the problem on one's own (56.9%) were the mostfrequently endorsed treatment barriers for participants.Additionally, a large proportion of participants felt thattreatment would not work (50.9%), worried about the costof treatment (49.9%), or lacked insurance coverage to payfor treatment (47.1%) (Table 4).

Barriers to treatment seeking: Ethnic differences

On all three barrier levels, there was a significant overalleffect of ethnicity after controlling for income and insurance(see Table 5). Pairwise comparisons for logistic and financialbarriers illustrated that significantly more Latinos endorsedlogistic and financial barriers than Caucasians (P=.006). Inthe stigma, shame, and discrimination category, significantlymore Latinos endorsed barriers than Caucasian as well(P=.046), and Asian participants endorsed significantlyfewer barriers than Caucasians in this category (P=.002).Finally, in the treatment perception and satisfaction category,pairwise comparisons revealed that significantly moreLatinos endorsed barriers than Caucasians (P=.023) andsignificantly fewer Asians endorsed barriers in this categorythan Caucasians (P=.012).

Discussion

The current study examined rates and patterns oftreatment utilization and barriers to treatment in an internetsample with symptoms consistent with a diagnosis of BDD.Similar to previous studies on BDD, the mean BDD

Table 3Barriers to seeking treatment

Barriers to treatment variablesWhole sample (%)total n

Logistic and financial barriersI was worried about how much it would cost. (49.9) 200Health insurance would not cover treatment. (47.1) 189I was unsure about who to see or where to go. (42.1) 169I thought it would be too inconvenient or taketoo much time.

(35.9) 144

I had problems with transportation or scheduling. (26.2) 105I could not get an appointment. (15.7) 63I could not choose the provider I wanted to see. (14.7) 59Stigma, shame, and discrimination barriersI wanted to handle it on my own. (56.9) 228I felt ashamed of my problems. (55.6) 223I felt ashamed of needing help for my problem. (54.1) 217I worried about what people would think if theyknew I was in treatment.

(45.6) 183

I was afraid of being criticized by my familyif I sought psychiatric help.

(40.4) 162

I was not comfortable discussing my problemswith a health professional.

(33.4) 134

I was scared about being put in a hospital againstmy will.

(26.9) 108

Treatment satisfaction and perception barriersI didn't think treatment would work. (50.9) 204I received treatment before and it didn't work. (27.7) 111I was not satisfied with the services thatwere available.

(22.4) 90

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symptom severity of the present sample fell within themoderately severe range [32].

Our internet sampling method provides a uniqueopportunity to learn more about individuals with bodydysmorphic symptoms. As an internet study, participants

Table 4Barriers to seeking treatment by ethnicity

Barriers to treatment variablesCt

Logistic and financial barriersI was worried about how much it would cost. (Health insurance would not cover treatment. (I was unsure about who to see or where to go. (I thought it would be too inconvenient or take too much time. (I had problems with transportation or scheduling. (I could not get an appointment. (I could not choose the provider I wanted to see. (Stigma, shame, and discrimination barriersI wanted to handle it on my own. (I felt ashamed of my problems. (I felt ashamed of needing help for my problem. (I worried about what people would think if they knew I was in treatment. (I was afraid of being criticized by my family if I sought psychiatric help. (I was not comfortable discussing my problems with a health professional. (I was scared about being put in a hospital against my will. (Treatment satisfaction and perception barriersI didn't think treatment would work. (I received treatment before and it didn't work. (I was not satisfied with the services that were available. (

were not required to come into a clinic in order to par-ticipate. Therefore, participants who would have beendeterred from taking part in the study because of treat-ment barriers or severely impairing BDD were not preventedfrom participating.

The first aim of the current study was to examine rates oftreatment utilization for participants with moderately severebody image concerns. Overall, a minority of the samplesought help from mental health and medical professionalsfor their body dysmorphic symptoms, with only 37.2%seeking treatment from a primary care physician, 30.5%from a psychiatrist, and 29.5% from a psychologist. Thesefindings may be a partial reflection of low rates of treatmentutilization reported by individuals with mental illness ingeneral [33]. It may also be accounted for by barriers totreatment, which are discussed later in this paper, as well aslow public and professional knowledge of BDD [6]. Withinthe general public, limited knowledge of BDD may preventindividuals from recognizing that they are suffering from adiagnosable, treatable disorder [34]. Within the medicalprofession, a lack of knowledge about psychologicaldisorders can lead to failure to detect mental illness[35,36]. This problem is exacerbated by low prioritizationof psychological screening and limited time to conductscreenings [37]. Even within the mental health careprofession, clinicians often lack knowledge of BDD, whichmay prevent accurate diagnosis and treatment [6].

Consistent with past research on BDD [31,38], partici-pants in the present study also reported high rates of seekingnonpsychiatric treatments for their BDD concerns. Forinstance, 24.6% of the sample had seen a dermatologist forbody image concerns. This finding is attributable to thetendency for individuals with BDD to consider their

aucasian (%)otal n

Latino (%)total n

African American (%)total n

Asian (%)total n

56.9) 269 (65.2) 23 (31.3) 16 (40.9) 4453.6) 265 (54.5) 22 (43.8) 16 (50.0) 4447.7) 266 (60.9) 23 (56.3) 16 (29.5) 4440.4) 265 (52.2) 23 (31.3) 16 (27.3) 4427.2) 265 (56.5) 23 (18.8) 16 (22.7) 4415.2) 265 (39.1) 23 (12.5) 16 (13.6) 4413.3) 264 (39.1) 23 (6.3) 16 (18.2) 44

65.8) 269 (82.6) 23 (43.8) 16 (34.1) 4462.2) 267 (87.0) 23 (56.3) 16 (42.2) 4561.8) 267 (73.9) 23 (50.0) 16 (37.8) 4549.8) 267 (73.9) 23 (50.0) 16 (37.2) 4346.3) 268 (47.8) 23 (37.5) 16 (31.8) 4437.8) 262 (54.5) 22 (31.3) 16 (25.6) 4330.6) 265 (39.1) 23 (18.8) 16 (13.6) 44

59.6) 267 (78.3) 23 (31.3) 16 (38.6) 4431.9) 263 (39.1) 23 (12.5) 16 (22.7) 4424.6) 265 (47.8) 23 (18.8) 16 (11.4) 44

Table 5Analysis of covariance of barriers to treatment groups by ethnicity

Barrier model SS df MS F P η2

Logistic and financial 50.34 4 12.59 3.426 .009 0.034Error 1432.33 391 3.66Shame, stigma, and discrimination 92.52 4 23.13 4.13 .003 0.041Error 2190.04 391 5.60Treatment satisfaction and perception 15.33 4 3.83 3.99 .004 0.039Error 375.94 391 0.96

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problems to be a physical defect, as opposed to a psy-chological illness [6]. For instance, one study of 200BDD subjects found that 64% had received nonpsychiatrictreatments for BDD symptoms [38]. However, it has beenshown that cosmetic procedures are an ineffectivetreatment for BDD [6]. In fact, cosmetic treatments canextend time without proper treatment, greatly increasecosts of the disorder, and worsen problems rather thanimprove them [6].

In addition, the present study examined what types oftreatment had been received by participants with BDDsymptoms. Participants who had received psychotherapyfor their BDD symptoms had primarily received talktherapy (35.1%), as opposed to CBT (17.4%). This resultis concerning, as research has documented CBT as the onlyempirically supported psychotherapy for BDD [10,11]. Incontrast, the findings regarding pharmacotherapy were moreencouraging. The most commonly prescribed medicationsfor the sample's BDD symptoms were SSRIs, which havebeen shown to be the psychopharmacologic treatment ofchoice for BDD [10,11]. This result implies that profes-sionals are knowledgeable about how to best treat BDDpharmacologically. While this finding is positive, overallrates of psychopharmacologic treatments were quite low(34.4% of the sample had taken SSRIs), indicating that manyindividuals who may benefit from medication therapy are notreceiving it. Furthermore, we did not assess dosages andlengths of treatment, so it is unclear whether patientsreceived adequate trials.

Furthermore, as hypothesized, participants with BDDsymptoms endorsed numerous and varied barriers totreatment including logistic and financial barriers; stigma,shame, and discrimination barriers, and treatment perceptionand satisfaction barriers. It is likely that these impediments totreatment partially account for the low rates of treatmentutilization reported in the present sample, and that thetendency for individuals with BDD to receive inappropriatetreatments serves to reinforce their barriers. In light of theseconcerning statistics, additional research on barriers totreatment in BDD as well as the development of treatmentdissemination programs are warranted.

Finally, in order to supplement the primary aims of thecurrent paper, ethnic differences in perceived barriers totreatment were also examined. As hypothesized, perceivedbarriers to treatment among the sample did differ by

ethnicity. In particular, a higher number of Latinos withBDD symptoms were found to endorse barriers to treatmentthan Caucasians in all three barriers categories, a finding thatconcurs with past research on barriers to treatment forLatinos with mental illness [39]. A distinct pattern alsoemerged in which fewer Asian participants than Caucasianparticipants reported concerns about stigma, shame, anddiscrimination as well as concerns about treatment notworking. Based on these results, one might hypothesize thatcertain aspects of Asian culture are protective againststigmatization as a barrier to treatment seeking. However,support for this hypothesis could not be found in the broaderbarriers to treatment literature. Another possible explanationis that Asian participants endorsed fewer impediments totreatment because of a desire to “save face” and hideembarrassment about symptoms and barriers [20,40,41].Ultimately, due to the low proportion of ethnic minorityparticipants in the present study, replication and extension ofthe present findings are required.

While there are advantages to using an internet samplingtechnique (as described above), this design also presentscertain limitations. First, participants in this sample were notdiagnosed by a clinician and thus it is possible that they had“real” appearance flaws. In place of a clinical diagnosis,participants' self-report data from the modified self-reportBDD-YBOCS and BDDQ were used to limit the sample tothose participants with symptoms consistent with a diagnosisof BDD. Second, the questionnaires used to collectinformation on participants' treatment history and perceivedbarriers to treatment have not been empirically validated andsome participants may have misunderstood the distinctionbetween the different therapeutic and pharmacologicalinterventions described within. In addition, informationabout outcomes of psychotherapy and pharmacotherapyfrom those patients who had engaged in therapy was notcollected. There was also a discrepancy in the timeframe forwhich treatment utilization (lifetime) and BDD symptoms(past week) were assessed, possibly exaggerating the effectof low treatment utilization. Finally, although an effort wasmade to recruit a diverse sample, the present sample wasnonetheless primarily female and Caucasian. Future studiesshould also aim to recruit an ethnically diverse sample. Theremay have also been a sampling bias toward individualswith access to and knowledge about computers/the internet,as the majority of study advertising was done via online

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websites related to BDD. However, some advertising wasalso done through flyers in the Boston area. Data onwhere participants encountered the study advertisement isnot available.

The present study addresses an important gap in the BDDliterature by examining patterns of treatment utilization andbarriers to treatment among individuals with BDD symp-toms. Findings demonstrated low rates of treatmentutilization among the sample. The likelihood that partici-pants would engage in treatment with dermatologists, plasticsurgeons, and dentists was similar to their likelihood ofengaging in treatment with psychologists or psychiatrists,despite past research demonstrating that the former treat-ments are ineffective for BDD [42]. Furthermore, resultsshowed that a majority of the samples are prevented fromseeking treatment by numerous and varied treatment barriers.These barriers were differentially endorsed by ethnicminority participants when compared to Caucasian partici-pants. The present findings represent an initial examinationof the low treatment utilization patterns among individualswith severe body image concerns and may be used to directfuture research in this domain.

Acknowledgments

David Judah Fund–Internal Donor Funding donated forresearch purposes at the Massachusetts General Hospital,Boston, MA.

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