Temporal dynamics of insight in body dysmorphic disorder: An ecological momentary assessment study

Individuals with body dysmorphic disorder (BDD) often lack insight into the nature of their perceived appearance flaws that are slight, if they exist at all. Despite the generally held assumption that insight fluctuates over time within individuals with BDD, its temporal instability and associated features remain unstudied. We examined insight as a multidimensional, contextually embedded, and dynamic factor using ecological momentary assessment (EMA), further assessing affect and self-esteem as potentially associated states. Thirty individuals with BDD and 30 mentally healthy controls (HCs) completed 6 days of EMA (M = 8.54 assessments per day, N = 3075 assessments in total). Multilevel analyses revealed substantial intraindividual fluctuations of insight dimensions (across 30 min to hours) that were more pronounced for individuals with BDD than for HCs. Poorer insight correlated with higher negative affect, lower positive affect, and lower self-esteem at concurrent time points in the BDD group. Considering all predictors at the same time point, poorer insight was characterized by lower self-esteem and, partly, negative affect in the BDD group. Across time, self-esteem and insight influenced each other reciprocally, with comparatively stronger effects for the prediction of poorer insight by previously lower self-esteem. These findings demonstrate that insight is a highly variable phenomenon in BDD, further suggesting a clinically and etiologically relevant link between self-esteem and insight in symptom maintenance. (PsycInfo Database Record (c) 2021 APA, all rights reserved).