A Preliminary Examination of the Associations Between Sleep Quality and Body Dysmorphia Symptoms Among Two Separate Samples of Adolescents

Abstract

Obsessive compulsive and related disorders have been linked to sleep disturbances. Given that adolescence is a core risk period for body dysmorphic disorder (BDD), and sleep difficulties are particularly prevalent during adolescence, the current study aims to examine associations between sleep quality and BDD symptoms among two separate samples of adolescents. It was hypothesized that lower reported sleep quality would be associated with higher reported BDD symptoms, even after controlling for anxiety and depression. Study 1 included 325 adolescents aged 11–18 years who completed an online survey via social media recruitment. The survey included questionnaires on BDD symptoms, sleep quality, and anxiety and depressive disorder symptoms. Study 2 included 396 adolescents who completed the same online survey. In study 1, a significant omnibus regression model accounted for 20.0% of the variance in adolescent BDD symptoms. After controlling for anxiety and depressive symptoms, adolescent sleep quality was significantly associated with BDD symptoms, with a small effect size (sr² = 0.02). Study 2 yielded similar results, with a significant omnibus regression model accounting for 26.5% of the variance in adolescent BDD symptoms, and significant associations between adolescent sleep quality and BDD symptoms yielding a small effect size (sr² = 0.01). Exploratory analyses in both studies demonstrated associations between difficulty returning to wakefulness and BDD symptoms. Adolescent sleep quality and BDD symptoms were linked, such that adolescents who reported lower quality sleep also reported higher levels of BDD symptoms. Future research can aim to replicate and extend these results using more rigorous (e.g., longitudinal, experimental) methods.

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Vol.:(0123456789)
Child Psychiatry & Human Development
https://doi.org/10.1007/s10578-025-01813-7
RESEARCH
A Preliminary Examination oftheAssociations Between Sleep Quality
andBody Dysmorphia Symptoms Among Two Separate Samples
ofAdolescents
SarahA.Bilsky1· LeilaC.Sachner1· RachealA.Embry1· KayceM.Hopper1
Accepted: 27 January 2025
© The Author(s) 2025
Abstract
Obsessive compulsive and related disorders have been linked to sleep disturbances. Given that adolescence is a core risk
period for body dysmorphic disorder (BDD), and sleep difficulties are particularly prevalent during adolescence, the current
study aims to examine associations between sleep quality and BDD symptoms among two separate samples of adolescents.
It was hypothesized that lower reported sleep quality would be associated with higher reported BDD symptoms, even after
controlling for anxiety and depression. Study 1 included 325 adolescents aged 11–18years who completed an online survey
via social media recruitment. The survey included questionnaires on BDD symptoms, sleep quality, and anxiety and depres-
sive disorder symptoms. Study 2 included 396 adolescents who completed the same online survey. In study 1, a significant
omnibus regression model accounted for 20.0% of the variance in adolescent BDD symptoms. After controlling for anxiety
and depressive symptoms, adolescent sleep quality was significantly associated with BDD symptoms, with a small effect size
(sr2 = 0.02). Study 2 yielded similar results, with a significant omnibus regression model accounting for 26.5% of the variance
in adolescent BDD symptoms, and significant associations between adolescent sleep quality and BDD symptoms yielding
a small effect size (sr2 = 0.01). Exploratory analyses in both studies demonstrated associations between difficulty returning
to wakefulness and BDD symptoms. Adolescent sleep quality and BDD symptoms were linked, such that adolescents who
reported lower quality sleep also reported higher levels of BDD symptoms. Future research can aim to replicate and extend
these results using more rigorous (e.g., longitudinal, experimental) methods.
Keywords Sleep quality· Adolescent· Body dysmorphia· Anxiety· Depression
Introduction
Body dysmorphic disorder (BDD) is a psychological dis-
order that involves preoccupation with perceived defects in
appearance that appear minimal or non-existent to others [3].
BDD is relatively common, with a lifetime prevalence rate of
2.4% [31]. Retrospective work among adults with BDD indi-
cated that the average age of onset for BDD was 16.7years,
while the modal age of onset was 12–13years [10]. Indeed,
work with a community sample of 3,149 adolescents found
that 1.7% of adolescents in the sample reported probable
BDD, while 3.4% of the sample reported subclinical BDD
[46]. Additionally, BDD symptoms appear to be distributed
dimensionally among adolescents, and adolescents who have
elevated BDD symptoms report distress and impairment,
even in the absence of crossing a diagnostic threshold [6]. In
light of evidence that BDD tends to be chronic [38], onsets
during adolescence [37], and earlier onset is associated with
higher levels of comorbidity [10], there is a need to identify
factors that may be associated with BDD symptoms during
adolescence.
Interestingly, emerging research suggests that sleep dis-
turbances may be important to consider in terms of BDD
symptoms during adolescence. Sleep disturbances are
common across individuals with psychopathology [5]. For
example, sleep disturbances have been consistently associ-
ated with depression [36], anxiety [21], and posttraumatic
stress disorder [4], suggesting that sleep disturbances may
represent a transdiagnostic factor associated with multiple
psychological disorders and symptoms. Recently, a nascent
* Sarah A. Bilsky
sabilsky@olemiss.edu
1 Department ofPsychology, University ofMississippi, 302B
Peabody Hall, Oxford, MS38655, USA
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Child Psychiatry & Human Development
literature has also implicated sleep disturbances in the devel-
opment and maintenance of obsessive–compulsive disorder
(OCD) and related disorders [22]. The obsessive compulsive
and related disorders (OCRD) category was introduced in
The Diagnostic and Statistical Manual of Mental Disorders,
Fifth Edition (DSM-5, [3]) and includes OCD along with
other disorders characterized by obsessive thoughts and
compulsive behaviors. These other disorders include exco-
riation disorder, hoarding disorder, trichotillomania, and
BDD.
Although little work to date has examined the associations
between sleep disturbances and BDD specifically, emerging
work has linked other OCRDs to alterations in sleep [22].
For example, compared to a group of healthy control par-
ticipants, participants with OCD reported increased subjec-
tive (i.e., sleep quality, sleep onset latency, sleep efficiency,
and daytime dysfunction) and objective sleep disturbances
(i.e., shorter sleep onset latency, lower total sleep time, lower
sleep efficiency, [25]). Further, a meta-analysis indicated that
OCD is related to disruptions in both the duration and timing
of sleep [35]. Notably, research among clinical samples dem-
onstrated that 92% of youth with pediatric OCD reported a
sleep-related problem, with 27.3% of youth with pediatric
OCD reporting five or more sleep-related problems [50].
Additionally, a clinical sample of non-depressed children
with OCD demonstrated significant reduced total sleep time
and longer wake periods after sleep onset than a matched
group of healthy control children [1]. Indeed, a recent review
demonstrated that youth with OCD report greater subjec-
tive sleep disturbances (i.e., poorer sleep quality, reduced
sleep duration and efficiency, worse daytime dysfunction,
and higher numbers of sleep disturbances) than age matched
healthy controls [44]. Beyond more general sleep distur-
bances, OCD symptoms have also been repeatedly linked to
self-reported insomnia symptoms among adults. For exam-
ple, after controlling for depressive symptoms, self-reported
insomnia symptoms were cross-sectionally [51] and longi-
tudinally [19, 20] associated with elevated OCD symptoms.
In contrast, among a sample of adolescents, while OCD
was prospectively related to increased self-reported insom-
nia symptoms, self-reported insomnia symptoms were not
prospectively linked to increased OCD symptoms after con-
trolling for baseline OCD symptoms [2]. This indicates that
the associations between OCD symptomology and insomnia
symptoms may vary as a function of developmental phase.
A small literature has examined the associations between
OCRDs other than OCD and sleep disturbances. For exam-
ple, a study among adults with trichotillomania and exco-
riation disorder indicated that adults with trichotillomania
and excoriation reported significantly more sleep difficulties
(i.e., total sleep problems, sleep quality, sleep disturbances,
use of sleep medication, and daytime dysfunction) than a
control sample of healthy adults, even after controlling for
anxiety and depression symptoms [43]. Additionally, among
a sample of 24 adults with hoarding disorder, insomnia
symptoms were positively associated with hoarding symp-
tom severity, even after controlling for diagnoses of depres-
sion and PTSD [40]. Taken together, these studies provide
preliminary evidence that subjective sleep disturbances may
be linked to OCRDs.
In the most relevant work to date, muscle dysmorphia
symptoms among adolescents and young adults were cross-
sectionally and prospectively associated with shorter self-
reported sleep duration and difficulty falling asleep. Spe-
cifically, symptoms related to appearance intolerance, drive
for size, and functional impairment were most strongly
associated with sleep disturbances [27]. Further, among a
sample of bodybuilders/fitness athletes (BoFA,n = 44) dur-
ing COVID-19, BoFA with probable muscle dysmorphia
reported significantly greater insomnia symptoms than
BOFA without probable muscle dysmorphia [28]. Next,
among a clinical sample of 66 adolescents with BDD, 48.5%
of adolescents in the sample reported clinically significant
insomnia symptoms [47]. Additionally, Sevilla-Cermeno
etal. [47] found that adolescents with clinically significant
insomnia symptoms reported more severe BDD symptoms,
worse functioning in daily activities, higher rates of co-
morbid depression, and were less likely to be considered
treatment responders/remitters compared to you with BDD
without clinically significant insomnia. In contrast, among
a clinical sample of 77 adults with BDD, approximately two
thirds of the sample reported elevated insomnia symptoms,
although sleep disruption was not associated with BDD
symptoms severity [8]. Additionally, results of Bernstein
etal. [8] study suggested that pre-treatment sleep disrup-
tion was not associated with treatment progress, while sleep
improvements were not associated with treatment improve-
ment. Given the limited body of work that has examined
how subjective sleep disturbances may be associated with
BDD symptoms (and the mixed results of the existing work),
there is a need to examine the association between subjective
sleep disturbances and BDD symptoms among adolescents.
There are a number of reasons to think that subjective
sleep disturbances may be associated with BDD symptoms
during adolescence. Sleep disturbances during adolescence
may present differently than sleep disturbances among
adults. For example, between 9 and 9.25h of sleep a night
are required for optimal cognitive and emotional function-
ing among adolescents [26], [48]. Unfortunately, only one
third of American high school students currently receive the
recommended amount of sleep each night [7]. The “perfect
storm model” of sleep during adolescence proposes that
the maturation of bioregulatory mechanisms coincide with
psychosocial factors to result in short, ill-timed, sleep [12,
23]. These changes coincide with earlier school start times
over the course of middle school and high school leading
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Child Psychiatry & Human Development
to greater levels of adolescent sleep deprivation and day-
time sleepiness [13]. Indeed, many adolescents experience a
mismatch between circadian phase and environmental sleep
demands leading to low quality sleep [53]. In light of evi-
dence that adults with OCRD report lower sleep quality than
healthy controls [33], and that low-quality sleep is associated
with increased mental health symptoms among adolescents
[29, 41], the current study aims to examine the associations
between adolescent sleep quality and BDD symptoms.
Given the evidence reviewed above, the aim of the current
study was to examine the associations between self-reported
adolescent sleep quality and adolescent BDD symptoms
among two separate samples of adolescents. A number of
hypotheses guided the current investigation. First, in Study
1, it was hypothesized that adolescents who reported lower
quality sleep would also report higher body dysmorphia
symptoms (Hypothesis 1). Given that a large body of work
has demonstrated that anxiety symptoms [29] and depres-
sive symptoms [43] are associated with sleep quality dur-
ing adolescence, as well as the association between nega-
tive emotionality and body dysmorphia symptoms [49], the
current study included anxiety and depressive symptoms as
covariates in current analyses. Next, the goal of Study 2 was
to replicate the findings from Study 1 using a separate, inde-
pendent sample of adolescents using an empirically valid
assessment of adolescent BDD symptoms. As with Study 1,
it was hypothesized that in Study 2, adolescent sleep quality
would be negatively associated with adolescent body dys-
morphia symptoms after controlling for anxiety and depres-
sive symptoms (Hypothesis 2). Finally, post-hoc explora-
tory analyses were conducted in both Study 1 and Study 2
to explore the associations between ASWS subscales (i.e.,
going to bed, falling asleep, maintaining sleep, reinitiating
sleep, and returning to wakefulness) and BDD symptoms.
Study 1 Methods
Participants andRecruitment
Participants for Study 1 were 325 adolescents between the
ages of 11 and 18years (Mage = 14.82years, SD = 1.11years).
In Study 1, adolescents reported the following gender identi-
ties: 92 adolescents identified as boys (28.3%), 162 adoles-
cents identified as girls (49.8%), 61 adolescents identified as
non-binary/third gender (18.8%), and 10 adolescents (3.1%)
did not provide data on their gender identity. In the current
study adolescents were able choose more than one racial/
ethnic identity leading to the following racial/ethnic back-
ground: Caucasian/White (75.1%), Hispanic/Latino (14.5%),
Asian American (11.4%), Black/African American (6.2%),
Native American (3.7%), and “Other” (4.9%). Unfortunately,
no norms have been published using the RCADS to assess
levels of nonbinary/third gender adolescent affective symp-
toms; therefore, this study does not report clinical eleva-
tions for youth who identified as nonbinary/third gender or
youth who declined to report their gender identity. However,
using T-scores and published norms [15], 26 adolescent boys
and girls reported borderline clinically significant depres-
sive symptoms, and 109 adolescent boys and girls reported
clinically significant depression scores. Twenty-six adoles-
cent boys and girls reported borderline clinically significant
anxiety scores, and 83 adolescent boys and girls reported
clinically significant generalized anxiety symptoms. Taken
together, this suggests that 53.1% of the adolescent boys
and girls in the current sample reported borderline or clini-
cally significant depression, and 42.9% of adolescent boys
and girls in the sample reported borderline or clinically
significant total anxiety scores. Due to experimenter error
described below in the measures section, we could not com-
pute clinical BDD scores.
Procedures
Adolescents were recruited through paid advertisements dis-
played on social media (i.e., Facebook and Instagram). Ads
for the study were displayed between March and August of
2021. Methods of the recruitment strategy used for the cur-
rent study have been described in more detail elsewhere [9].
Briefly, adolescents viewed an advertisement that contained
a picture of adolescents on their cell phones, the text on the
ad invited adolescents to participate in a study which aimed
to “learn more about adolescent emotions.” The advertise-
ment stated that the study had been approved by the insti-
tutional review board (IRB) at the institution. Consistent
with prior work done in samples of adolescents recruited
online [30], the IRB at the institution waived the requirement
for parental consent. Prior to taking the survey, adolescents
were informed that they could skip as many questions as
they chose, and at the end of the survey, adolescents were
offered an opportunity to enter into a raffle for the pros-
pect to win a $20.00 Amazon gift card. The current study
included a single attention check question (“what color is the
sky”). In order to be included in the current study, adoles-
cents had to provide the right answer to the attention check
question. The attention check question was answered by 434
adolescents. Of the adolescents who answered the attention
check question, 387 adolescents (89%) provided the correct
answer. The 325 adolescents who passed the attention-check
and completed necessary measures were included in the cur-
rent study.
Measures
Demographics. Adolescents provided information about
their age, gender, grade, and race/ethnicity.
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Child Psychiatry & Human Development
Body image questionnaire, child and adolescent ver-
sion (BIQ-C). BDD symptoms were assessed using the
Body Image Questionnaire Child and Adolescent Version
(BIQ-C; [52]). The BIQ-C assesses a number of symptoms
related to BDD (i.e., distress, appearance checking, impair-
ment, and avoidance). At the start of the measure, partici-
pants are asked to complete an initial question querying if
the adolescent has any appearance concerns. If the adoles-
cent denied appearance concerns, they were given a total
score of 0. If adolescents reported an appearance concern,
they were then allowed to report up to five body areas of
concern. They then responded to 12 items while thinking
about their areas of bodily concern (e.g., “how often do
you check your feature,” “how much do you feel like your
appearance is the most important thing about you?”). Due
to experimenter error, participants rated responses on a 1
(Never/Not at all) to 4 (Always/A lot) scale (instead of the
standard 0 to 8 scale employed for this measure in most
studies). Internal consistency in the current study was good
(α = 0.88).
Revised child anxiety and depression scale (RCADS).
Adolescent anxiety and depressive symptoms were assessed
using the Revised Child Anxiety and Depression Scale
(RCADS; [14]. The RCADS is a self-report measure that
consists of 47-items. It assesses anxiety and depressive
symptoms in children and adolescents and includes sub-
scales for social anxiety disorder, panic disorder, separation
anxiety disorder, obsessive compulsive disorder, general-
ized anxiety disorder, and major depressive disorder. A total
anxiety score can also be computed reflecting overall anxiety
symptoms. The current study employed the RCADS total
anxiety subscale and the depression subscale. Consistent
with previous work (Timpano etal. 2014), modified total
RCADS depression and total anxiety scores were calculated
by removing two sleep items from the depression scale (i.e.,
“I have trouble sleeping” and “I am tired a lot”) and one item
from the anxiety scale (“I feel scared if I have to sleep on
my own”). This was done in order to reduce spurious cor-
relations between the RCADS depression and total anxiety
subscales with adolescent sleep quality. Adolescents rated
the frequency of which they experience the statements listed
(e.g., “I feel worthless,” “I worry bad things will happen to
me”) on a 0 (Never) to 3 (Always) Likert-type scale. The
RCADS has good psychometric properties [15]. In the cur-
rent sample, internal consistency was good to excellent
(αdepression scale = 0.89, αanxiety = 0.96).
Adolescent sleep wake scale (ASWS). Adolescent sleep
quality was measured using the Adolescent Sleep Wake
Scale (ASWS; [32]. The ASWS is a 28-item measure that
consists of a total score (reflecting overall sleep quality) and
five subscales: going to bed (“I have trouble making myself
go to bed at bedtime”), falling asleep (“I have trouble going
to sleep”), maintaining sleep (“During the night, I toss and
turn in my bed”), reinitiating sleep (“After waking up during
the night, I have trouble going back to sleep”), and returning
to wakefulness (“In the morning, I wake up feeling rested
and alert”). Adolescents read each item and rated how often
they had experienced each problem on a six-point rating
scale from 1 (always) to 6 (never). Lower scores indicate
lower quality sleep. The ASWS has demonstrated adequate
internal consistency and validity in adolescents (Le Bour-
geois etal. 2005. In the current sample, internal consist-
ency was acceptable to excellent (αtotal = 0.91,αgoingtobed =
0.79; αfallingasleep = 0.81; αmaintainingsleep = 0.82; αreinitiatingsleep
= 0.79; αreturningtowakefulness = 0.84).
Analytic Approach
As a first step, assumptions of normality were tested. Next,
descriptive statistics and correlations were computed.
Third, two hierarchical multiple regression analyses were
conducted. The model had two steps: (1) the main effect of
adolescent anxiety and depressive symptoms were entered at
step 1; and (2) in the next step adolescent sleep quality was
entered simultaneously with adolescent anxiety and depres-
sive symptoms. Next, a separate regression was conducted
for exploratory analyses. The model had two steps: (1) the
main effect of adolescent anxiety and depressive symptoms
were entered at step 1; and (2) in the next step adolescent
ASWS subscales (i.e., going to bed, falling asleep, maintain-
ing sleep, reinitiating sleep, and returning to wakefulness)
were entered simultaneously with adolescent anxiety and
depressive symptoms. For the purposes of this investiga-
tion, sr2 was used as an index of effect size (0.01 = small,
0.09 = medium, and 0.25 = large; [16]. Bootstrapping was
employed in all regression analyses.
Study 1 Results
Descriptive Statistics andCorrelations
Descriptive information and zero order correlations are pre-
sented in Table1. Consistent with expectations and prior
literature, BDD symptoms were significantly positively cor-
related with adolescent anxiety and depressive symptoms,
and negatively correlated with adolescent sleep quality.
Adolescent sleep quality was significantly negatively cor-
related with adolescent anxiety and depressive symptoms.
Adolescent anxiety and depressive symptoms were signifi-
cantly positively associated with one another.
Primary Hypothesis Test
A significant omnibus regression model [F (3,324) = 26.94,
p < 0.001] emerged that accounted for 20.1% of the variance
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Child Psychiatry & Human Development
in adolescent BDD symptoms. As noted in Table2, in step
1, adolescent anxiety symptoms (sr2 = 0.03) and depressive
symptoms (sr2 = 0.01) were significantly associated with
adolescent BDD symptoms, these effects were small in
magnitude. In step 2, after controlling for adolescent anxi-
ety and depressive symptoms, adolescent sleep quality was
a significant predictor of adolescent BDD symptoms, this
effect was small in magnitude (sr2 = 0.02).
Exploratory Analyses
A significant omnibus regression model [F (7,324) = 11.87,
p < 0.001] emerged that accounted for 20.8% of the variance
in adolescent BDD symptoms. As noted in Table3, in step
1, adolescent anxiety symptoms (sr2 = 0.03) and depressive
symptoms (sr2 = 0.01) were significantly associated with
adolescent BDD symptoms, these effects were small in
magnitude. In step 2, the ASWS subscales (i.e., going to
bed, falling asleep, maintaining sleep, reinitiating sleep, and
returning to sleep) were added to the regression model. In
this final step of the model, adolescent depressive symp-
toms were no longer associated with adolescent BDD symp-
toms. Additionally, after controlling for adolescent anxiety
and depressive symptoms, returning to wakefulness was
the only ASWS subscale associated with adolescent BDD
symptoms, this effect was small in magnitude (sr2 = 0.01),
and approached statistical significance (p = 0.053).
Study 2 Methods
Participants, Recruitment, andProcedure
In order to ensure that the results of Study 1 replicated, the
aim of Study 2 was the examine the associations between
sleep quality and BDD symptoms among a separate sample
of adolescents. Recruitment procedures for Study 2 were
similar to the methods for Study 1. In Study 2, 549,717
participants were shown the advertisement. Next, 2104
individuals clicked on the advertisement and were taken
to the survey. Advertisements for the study ran between
February and March of 2023. The current study included
two attention-check questions (“what color is the sky”
and “click the option that says C”) that adolescents had to
answer correctly in order to be included in Study 2. Four
hundred and ninety-three adolescents answered the atten-
tion-check questions, and of these, 483 (98%) adolescents
answered the question “what color is the sky” correctly.
In terms of the second question, 450 (91%) adolescents
answered the question “pick option C” correctly. The 396
Table 1 Descriptive data and
zero-order relations between
relevant continuous variables
Correlations for Study 1 located in the top half of the table, correlations for study 2 located in the bottom
half of the table. BDD = Body Dysmorphia Symptoms, ASWS = Adolescent Sleep Quality, RCADS_Anxi-
ety = adolescent anxiety symptoms, RCADS_Depression = adolescent depression symptoms
** p < 0.01, *** p < 0.001 (two-tail)
M (SD)
Study 1
Mean (SD)
Study 2
1234
1. BDD 20.21 (14.89) 24.96 (19.47) – −0.39*** 0.41*** 0.38***
2. ASWS Total 95.54 (22.34) 101.57 (21.73) −0.39*** – −0.60*** −0.61***
3. RCADS_Anxiety 49.30 (22.54) 45.22 (19.91) 0.49*** −0.56*** – 0.77***
4. RCADS_Depression 11.89 (5.76) 10.21 (5.19) 0.45*** −0.56*** 0.79*** –
Table 2 Study 1: Adolescent sleep problems and anxiety as well as depression symptoms as predictors of body dysmorphia symptoms
BDD Body Dysmorphia Symptoms; ASWS adolescent Sleep Wake Scale; RCADS_Anxiety Adolescent Anxiety Symptoms; RCADS_Depression
adolescent Depression Symptoms
*p < 0.005, ** p < 0.01, *** p < 0.001 (two-tail)
ΔR2B [95% CI] β SE sr2p
Dependent Variable: BDD Symptoms
Step 1 0.177***
RCADS_Anxiety 0.187 [.087, .288] 0.287 0.051 0.03*** < 0.001
RCADS_Depression 0.408[.008, .808] 0.158 0.203 0.01* 0.046
Step 2 0.024**
RCADS_Anxiety 0.144 [.040, .247] 0.220 0.052 0.02** 0.007
RCADS_Depression 0.220 [−0.192, .631] 0.085 0.209 0.00 0.295
ASWS total −0136 [−0.220, −0.051] −0.206 0.045 0.02** 0.002
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Child Psychiatry & Human Development
adolescents who passed both attention-check questions and
completed measures for the current study were included
in the current study (Mage = 15.93years, SD = 1.49years).
In the current sample, 167 adolescents identified as
boys (42.4%), 185 adolescents identified as girls (47.0%),
and 42 adolescents identified as non-binary/third gen-
der (10.7%). In the current study adolescents were able
choose more than one racial/ethnic identity leading to
the following racial/ethnic background: Caucasian/White
(64.1%), Asian American (16.7%), Black/African Ameri-
can (13.4%), Hispanic/Latino (13.4%), Native American
(5.8%), and “Other” (1.3%). As in Study 1, to the best
of our knowledge, no norms have been published using
the RCADS to assess levels of nonbinary/third gender
adolescent affective symptoms; therefore, this study does
not report clinical elevations for youth who identified as
nonbinary/third gender or youth who declined to report
their gender identity. However, using T-scores and pub-
lished norms [15], 43 adolescent boys and girls reported
borderline clinically significant depressive symptoms, and
95 adolescent boys and girls reported clinically significant
depression scores. Forty-nine adolescent boys and girls
reported borderline clinically significant anxiety scores,
and 77 adolescent boys and girls reported clinically sig-
nificant anxiety symptoms. Taken together, this suggests
that 43.5% of the adolescent boys and girls in the current
sample reported borderline or clinically significant depres-
sion, and 39.7% of adolescent boys and girls in the sam-
ple reported borderline or clinically significant total anxi-
ety scores. In terms of BDD scores, based on the norms
published by Schneider etal. [45] 26.5% of adolescent
girls, and 45.9% of adolescent boys in the current sample
reported elevated BDD symptoms.
Measures
Demographics. Adolescents provided information about
their age, gender, grade, and race/ethnicity.
Body image questionnaire, child and adolescent ver-
sion-9 item version (BIQ-C-9). The Body Image Ques-
tionnaire Child and Adolescent Version-9 Item Version
(BIQ-C-9; [45, 52] was used to assess adolescent BDD
symptoms. The BIQ-C-9 is similar to the BIQ-C described
in Study 1 (see full details above), but uses 9 items rather
than 12. In previous work, the BIQ-C-9 has demonstrated
good internal consistency in male (α = 0.86) and female
(α = 0.89) adolescents, and has been shown to have supe-
rior model fit to the 12-item BIQ-C [45]. In Study 2,
consistent with empirical precedent, participants rated
responses on a 0 (not at all distressing) to 8 (extremely
distressing) scale. Internal consistency in the current study
was excellent (α = 0.90).
Revised child anxiety and depression scale (RCADS).
See Study 1 for a complete description. In the cur-
rent sample, internal consistency was good to excellent
(αdepression scale = 0.87, αanxiety = 0.95).
Adolescent sleep wake scale (ASWS). See Study 1 for a
complete description. In the current sample, internal consist-
ency was acceptable to excellent (αtotal = 0.91; αgoingtobed =
0.72; αfallingasleep = 0.77; αmaintainingsleep = 0.78; αreinitiatingsleep
= 0.79; αreturningtowakefulness = 0.84).
Analytic Approach
The analytic approach for Study 2 was identical to the
approach used in Study 1.
Table 3 Study 1: adolescent
sleep problems subscales and
anxiety as well as depression
symptoms as predictors of body
dysmorphia symptoms
BDD Body dysmorphia symptoms; ASWS adolescent sleep wake scale; RCADS_Anxiety adolescent anxiety
symptoms; RCADS_Depression adolescent depression symptoms
*p < 0.05, ** p < 0.01, *** p < 0.001 (two-tail)
ΔR2B [95% CI] β SE sr2p
Dependent variable: BDD symptoms
Step 1 0.177***
RCADS_Anxiety 0.187 [0.087, 0.288] 0.287 0.051 0.03*** < .001
RCADS_Depression 0.408 [0.008, 0.808] 0.158 0.203 0.01* 0.046
Step 2 0.031*
RCADS_Anxiety 0.152 [0.047, 0.258] 0.233 0.054 0.02** 0.005
RCADS_Depression 0.184 [−0.238, 0.607] 0.071 0.215 0.00 0.391
Going to bed −0.224[−0.586, 0.138] −0.080 0.184 0.00 0.225
Falling asleep −0.020 [−0.368,.327] −0.009 0.177 0.00 0.908
Staying asleep −0.083 [−0.364, 0.199] −0.037 0.143 0.00 0.564
Reinitiating sleep −0.112 [−0.429, 0.206] −0.046 0.161 0.00 0.489
Returning to Wakefulness −0.340 [−0.684, 0.005] −0.120 0.175 0.01 0.054
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Child Psychiatry & Human Development
Study 2 Results
Descriptive Statistics andCorrelations
Descriptive information and zero order correlations are
presented in Table1. BDD symptoms were significantly
positively correlated with adolescent anxiety and depressive
symptoms, and negatively correlated with adolescent sleep
quality. Adolescent sleep quality was significantly negatively
correlated with adolescent anxiety and depressive symp-
toms. Adolescent anxiety and depressive symptoms were
significantly positively associated with one another.
Primary Hypothesis Test‑Replication ofStudy 1
Findings
Consistent with Study 1, a significant omnibus regression
model [F (3,395) = 47.04, p < 0.001] emerged that accounted
for 26.5% of the variance in adolescent BDD symptoms. As
noted in Table4, in step 1, adolescent anxiety symptoms
(sr2 = 0.05) and depressive symptoms (sr2 = 0.01) were sig-
nificantly associated with adolescent BDD symptoms, these
effects were small in magnitude. In step 2, after controlling
for adolescent anxiety and depressive symptoms, adolescent
sleep quality was a significant predictor of adolescent BDD
symptoms, this effect was small in magnitude (sr2 = 0.01).
Exploratory Analyses
Consistent with Study 1, a significant omnibus regression
model [F (7395) = 21.88, p < 0.001] emerged that accounted
for 28.3% of the variance in adolescent BDD symptoms. As
noted in Table5, in step 1, adolescent anxiety symptoms
(sr2 = 0.05) and depressive symptoms (sr2 = 0.01) were sig-
nificantly associated with adolescent BDD symptoms, these
effects were small in magnitude. In step 2, the ASWS sub-
scales (i.e., going to bed, falling asleep, maintaining sleep,
reinitiating sleep, and returning to sleep) were added to the
regression model. In this final step of the model, adolescent
depressive symptoms were no longer associated with ado-
lescent BDD symptoms. Additionally, after controlling for
adolescent anxiety and depressive symptoms, returning to
wakefulness was the only ASWS subscale associated with
adolescent BDD symptoms, this effect was small in magni-
tude (sr2 = 0.02).
Discussion
The aim of the current study was to extend the literature
linking sleep disturbances to OCRDs by examining the asso-
ciation between sleep quality and BDD symptoms among
two separate samples of adolescents. Results of both stud-
ies suggested that adolescent sleep quality was negatively
associated with adolescent BDD symptoms, such that ado-
lescents who reported lower quality sleep also tended to
report higher levels of BDD symptoms. Post-hoc explora-
tory analyses expanded on these results, demonstrating that
the only ASWS subscale associated with BDD symptoms
was the “returning to wakefulness” subscale [this subscale
approached significance (p = 0.540), in Study 1, and reached
conventional levels of significance (p < 0.001) in Study 2].
It is noteworthy that these results were significant after con-
trolling for both anxiety and depressive symptoms. Although
the current data did not come from clinical samples, they
extend prior research (e.g., [22] and provide preliminary
evidence that BDD symptoms among youth may be associ-
ated with lower quality sleep. The current results suggest a
number of important future research directions.
First, in both studies, the association between sleep qual-
ity and BDD symptoms maintained significance after con-
trolling for both anxiety and depressive symptoms. This is
partially consistent with other work examining the asso-
ciation between OCRDs and sleep [43, 51]. Both depres-
sion [36] and anxiety [21] symptoms have been identified
Table 4 Study 2: Adolescent
sleep problems and anxiety as
well as depression symptoms as
predictors of body dysmorphia
symptoms
BDD Body dysmorphia symptoms; ASWS adolescent sleep wake scale; RCADS_Anxiety adolescent anxiety
symptoms; RCADS_Depression adolescent depression symptoms
*p < 0.05, ** p < 0.01, *** p < 0.001 (two-tail)
ΔR2B [95% CI] β SE sr2p
Dependent variable: BDD symptoms
Step 1 0.252***
RCADS_Anxiety 0.362 [0.226, 0.497] 0.370 0.069 0.05*** < 0.001
RCADS_Depression 0.585 [0.066, 1.04] 0.156 0.264 0.01* 0.027
Step 2 0.013**
RCADS_Anxiety 0.316 [0.178, 0.445] 0.323 0.070 0.03** < 0.001
RCADS_Depression 0.425 [−0.250, 0.689] 0.113 0.269 0.00 0.115
ASWS total −0.127 [−0.220, −0.032] −0.142 0.048 0.01** 0.009
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Child Psychiatry & Human Development
as significant correlates of sleep difficulties, and tend to be
highly comorbid with BDD symptoms during adolescence
[34]. Interestingly, in the current study, only adolescent anxi-
ety and adolescent sleep quality were significantly linked to
adolescent BDD symptoms. In contrast, adolescent depres-
sive symptoms were not associated with adolescent BDD
symptoms. This was surprising in light of previous research
suggesting that BDD symptoms are associated with depres-
sive symptoms [39]. Notably adolescent depressive and anx-
iety symptoms evidenced strong correlations in the current
study (r = 0.77–0.79). Although the VIF (1.54–2.74) and tol-
erance values (0.36–0.38) in the current study were within
an acceptable range [11], it is possible that the null depres-
sion result was due to multicollinearity. Therefore, moving
forward, it will be important to replicate and refine knowl-
edge of the association between BDD symptoms, anxiety
symptoms, depressive symptoms, and sleep quality among
youth. For example, future work could meaningfully extend
the literature by examining the associations between sleep
quality, affective symptoms, and BDD symptoms prospec-
tively or using different measures of adolescent anxiety and
depressive symptoms. Although the current study provides
valuable initial support for an association between sleep
quality and BDD symptoms, it is not possible to determine
the directionality of these associations. Indeed, it is possible
that given the cross-sectional nature of the current findings,
BDD symptoms may interfere with adolescent sleep qual-
ity (c.f., adolescent sleep quality affecting BDD symptoms),
or these associations may be bidirectional. Longitudinal
approaches would allow researchers to examine the direction
of these effects, and if sleep quality and BDD symptoms may
be bidirectionally associated with one another. Additionally,
prospective data collections would allow for more complex
analytical models (e.g., longitudinal mediation models, [17])
designed to parse apart the associations between sleep qual-
ity, BDD symptoms, and internalizing symptoms over time.
Post-hoc exploratory analyses suggested that the only
subscale of the ASWS that was associated with BDD symp-
toms among adolescents was the returning to wakefulness
scale. The returning to wakefulness scale reflects how rested
adolescents feel upon waking in the morning. The subscale
includes items such as “In the morning, I wake up and feel
ready to get up for the day” and “I have trouble getting out
of bed in the morning.” The association between the return-
ing to wakefulness scale approached significance in Study 1
and reached significance in Study 2, although its effect size
was small in both studies. These results provide preliminary
evidence that adolescents who report feeling less rested upon
waking are also more likely to report higher BDD symp-
toms. Previous research among adolescents demonstrated
adolescents with a circadian preference for eveningness (i.e.,
adolescents who prefer later bed and rise times) also report
significantly more difficulty returning to wakefulness in the
morning than adolescents who prefer earlier wake and bed
times [53]. The exploratory results in the current study sug-
gest that it may, therefore, be important to consider adoles-
cent chronotype in relation to BDD symptoms. To the best
of our knowledge, no work to date has examined the associa-
tion between chronotype and BDD symptoms. In the most
relevant work to date, although chronotype was not prospec-
tively related to the development of OC symptoms among
a sample of adolescents [2], chronotype was prospectively
linked to OC symptoms after controlling for baseline OC
and depressive symptoms among adults [9]. Therefore, and
important next step in this line of work may be to examine if
chronotype may be associated with BDD symptoms among
Table 5 Study 1: Adolescent sleep problems subscales and anxiety as well as depression symptoms as predictors of body dysmorphia symptoms
BDD Body dysmorphia symptoms; ASWS adolescent sleep wake scale; RCADS_Anxiety adolescent anxiety symptoms; RCADS_Depression ado-
lescent depression symptoms
*p < 0.05, ** p < 0.01, *** p < 0.001 (two-tail)
ΔR2B [95% CI] β SE sr2p
Dependent variable: BDD symptoms
Step 1 0.252***
RCADS_Anxiety 0.362 [0.226, 0.497] 0.370 0.069 0.05*** < 0.0001
RCADS_Depression 0.585 [0.066, 1.04] 0.156 0.264 0.01* 0.027
Step 2 0.031**
RCADS_Anxiety 0.337 [0.192, 0.481] 0.344 0.074 0.04*** < 0.001
RCADS_Depression 0.281 [−0.256, 0.817] 0.075 0.273 0.00 0.304
Going to bed −0.089 [−0.557, 0.380] −0.022 0.238 0.00 0.711
Falling asleep 0.150 [−0.297, 0.597] 0.046 0.227 0.00 0.509
Staying asleep −0.228 [−0.662, 0.206] −0.068 0.221 0.00 0.301
Reinitiating sleep 0.048 [−0.359, 0.450 0.014 0.206 0.00 0.824
Returning to wakefulness −0.642 [−0.998, −0.285] −0.188 0.181 0.02*** < 0.001
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Child Psychiatry & Human Development
both adolescents and adults. This may help elucidate results
of the current study.
Next, moving forward, there is a need to better understand
why sleep quality may be associated with BDD symptoms.
Storch etal. [50] outlined a number of possible reasons
that youth with OCRD symptoms may be more likely to
report lower quality sleep than youth without OCRD symp-
toms including: heightened levels of anxiety/physiological
arousal, engagement in rituals that may interfere with sleep
onset, and more frequent cognitive/perseverative symptoms
that may interfere with sleep. Reynolds etal. [42] expanded
on this to propose a model of factors that may underlie the
association between OCD and sleep difficulties in children.
The model suggests that OC relevant nighttime routines/
rituals may increase pre-sleep arousal, delay bedtime, and
elicit parental accommodation thereby increasing sleep onset
latency and restricting sleep [42]. This restricted sleep may
lead to increased obsessions and emotional inhibition, which
likely bidirectionally maintain one another. The degree to
which such a model may apply to adolescent BDD remains
an empirical question. Additionally, it is unclear how self-
reported sleep quality may map onto these models. There-
fore, moving forward, future research can usefully examine
if similar processes may be at play among youth with BDD
symptoms, and if youth with BDD symptoms evidence simi-
lar alterations in sleep to youth with other OCRDs using
more objective measures (i.e., actigraphy, polysomnography)
and other self-report measures (e.g., insomnia measures).
There were a number of limitations to the current study.
The first limitation is the generalizability of the findings in
the present samples. It is possible that both study samples
were subject to self-selection bias, as participants were
recruited via social media, and there were notably fewer
participants engaging in the studies than the number of indi-
viduals who received ads for the studies and who clicked
on the survey links. Additionally, given the rising popu-
larity of using social media to recruit adolescents [24], it
will be important to improve knowledge of the strengths
(e.g., increased access to adolescents) and potential weak-
nesses (e.g., limited oversight of survey completion) of this
recruitment approach. Second, the samples for both studies
consisted of primarily White adolescents. Future research
should examine the generalizability of these findings to non-
White samples. Third, the current work relied primarily on
self-report assessments of sleep. Moving forward, it will be
important to utilize objective sleep measures (e.g., actig-
raphy, polysomnography) to assess associations between
BDD symptoms and sleep among adolescents. Relatedly,
it is important to note that while the results of the current
study are statistically significant, the effect sizes are small.
It is possible that the significant results in the current study
may be attributed to shared method variance [17]. Replicat-
ing the current findings using objective sleep measures will
help clarify the nature of the association between sleep and
BDD symptoms during adolescence. Additionally, future
research should consider exploring more specific areas of
sleep disturbances beyond general sleep quality (e.g., insom-
nia symptoms, sleep onset latency, sleep efficiency, [22],
as these may highlight more specific associations between
sleep disturbances and body dysmorphia symptoms. Fourth,
the current sample consisted of primarily non-clinical popu-
lations of adolescents. Although previous work indicates that
BDD symptoms are distributed dimensionally among ado-
lescents [6], moving forward, it will be important to exam-
ine these associations in clinical samples, using structured
clinical interviews. Indeed, between 10 and 50% of adoles-
cents in the current sample reported borderline or clinically
elevated affective symptoms, moving forward, the current
associations should be replicated among a larger sample of
clinical adolescents. In particular, in Study 2, the number
of boys in the current sample that reported elevated BDD
symptoms was notably high. Clinical cutoff scores suggested
by Schneider etal. [45] were used to calculate BDD eleva-
tions, but it is important to note that the threshold for meet-
ing elevation is lower for adolescent boys (a score of 25)
than girls (a score of 41). Moving forward, it will be impera-
tive to examine the associations between sleep quality and
BDD symptoms using more rigorous assessment methods to
ensure current findings replicate. Next, the current study did
not examine the role of OCD symptoms in the association
between sleep quality and BDD symptoms. This is a notable
limitation as BDD and OCD symptoms often co-occur [18].
Moving forward, studies can usefully expand on the current
findings by carefully considering the role OCD symptoms
may play in the association between sleep quality and BDD
symptoms. Finally, in Study 1, due to experimenter error,
participants responded to the BIQ-C on a 0 to 4 scale (c.f.,
a 0–8 scale). In order to address this concern, Study 2 used
the appropriate scaling for the BIQ-C-9. Nonetheless, this
is a notable limitation of the current work, and future work
should endeavor to replicate current findings using appropri-
ate scaling.
Author Contribution SB wrote the main manuscript text and ran sta-
tistical analyses. LS assisted with manuscript writing and data analy-
sis. RE assisted with manuscript review and manuscript writing. KH
assisted with statistical analyses and manuscript review. All authors
reviewed the manuscript.
Funding This study was funded by a grant from the Sally McDonnell
Barksdale Honors College at the University of Mississippi awarded to
Emily K. Olson and Kaylan Melvin.
Data Availability Data will be made available upon request.
Declarations
Conflict of interest The authors declare no competing interests.
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Child Psychiatry & Human Development
Ethics Approval This study was performed in line with the principles of
the Declaration of Helsinki. Approval was granted by the Ethics Com-
mittee of University of Mississippi (IRB # IRB #21-030, #23-019).
Open Access This article is licensed under a Creative Commons Attri-
bution 4.0 International License, which permits use, sharing, adapta-
tion, distribution and reproduction in any medium or format, as long
as you give appropriate credit to the original author(s) and the source,
provide a link to the Creative Commons licence, and indicate if changes
were made. The images or other third party material in this article are
included in the article’s Creative Commons licence, unless indicated
otherwise in a credit line to the material. If material is not included in
the article’s Creative Commons licence and your intended use is not
permitted by statutory regulation or exceeds the permitted use, you will
need to obtain permission directly from the copyright holder. To view a
copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
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