Vol.:(0123456789) 1 3 Cognitive Therapy and Research https://doi.org/10.1007/s10608-019-10069-0 ORIGINAL ARTICLE Social Avoidance as a Predictor of Psychosocial Functioning in Body Dysmorphic Disorder: A Prospective Longitudinal Analysis Timothy R. Ritzert 1  · Madeline Brodt 2  · Megan M. Kelly 3,4,5  · William Menard 6  · Katharine A. Phillips 7,8 © Springer Science+Business Media, LLC, part of Springer Nature 2019 Abstract Individuals with body dysmorphic disorder (BDD) experience elevated social avoidance, both as a consequence and inde- pendent of BDD concerns. To explore how social avoidance relates to the long-term course of functioning for people with BDD, this prospective longitudinal study evaluated the hypothesis that initial social avoidance would predict changes in psy- chosocial functioning over 3 years, such that greater initial social avoidance would predict worsening functioning. At intake, individuals with BDD (N = 200) completed measures of social avoidance independent of BDD, social avoidance due to BDD or any other source, overall psychosocial functioning, and psychosocial functioning in specifc domains. Overall and specifc functioning was prospectively evaluated at three subsequent yearly follow-up assessments. Mixed model analyses evaluated the relation between baseline social avoidance and changes in functioning. Results provided mixed support for hypotheses, indicating that higher baseline social avoidance independent of BDD predicted worsening functioning in two of the four overall functioning indices and in both specifc domains—interpersonal relationship quality and work/academic/household functioning. Higher global social avoidance (due to BDD or any other source) predicted poorer overall functioning for two of the four global functioning indices but did not predict functioning in either specifc domain. Social avoidance, both related and unrelated to body image, might play an important role in the trajectory of psychosocial functioning for people with BDD. Keywords Body dysmorphic disorder · Psychosocial functioning · Social anxiety · Social avoidance · Relationships Introduction Body dysmorphic disorder (BDD) is characterized by dis- tressing or impairing preoccupation with nonexistent or slight defects in appearance (e.g., “ugly” skin blemishes) and repetitive behaviors in response to the appearance pre- occupation, such as excessively checking one’s appearance in a mirror, that function to temporarily reduce distress (American Psychiatric Association 2013). The disorder is associated with severe impairment in psychosocial function- ing, emotional distress, and low quality of life (Kelly et al. 2017; Marques et al. 2011). BDD is linked with high rates of suicidality and psychiatric hospitalization (Phillips et al. 2005a, b; Phillips and Diaz 1997), poor social functioning and adjustment (Phillips et al. 2005a, b), and occupational and academic impairment (Didie et al. 2008). People with BDD experience impaired interpersonal relationships; they report low-quality relationships with immediate family, partners, and friends, and impairment in domains such as recreation and leisure (Phillips et al. 2005a, b; Pinto and Phillips 2005). These psychosocial functional impairments endure across time. In a prospective, longitudinal study using the same sample of individuals with current or past BDD as the pre- sent report, Phillips et al. (2008) tracked psychosocial func- tioning for 3 years. The researchers found that global social * Timothy R. Ritzert ritzerttr@longwood.edu 1 Department of Psychology, Longwood University, 201 High Street, Farmville, VA 23909, USA 2 University of Massachusetts Boston, Boston, USA 3 Edith Nourse Rogers Memorial Veterans Hospital, Bedford, USA 4 Alpert Medical School of Brown University, Providence, USA 5 University of Massachusetts Medical School, Worcester, USA 6 Butler Hospital, Providence, USA 7 Weill Cornell Medical College, New York, USA 8 New York-Presbyterian Hospital, New York, USA