Real-world substance use in body dysmorphic disorder: An ecological momentary assessment study of motives, contexts, and suicidal ideation

Body dysmorphic disorder (BDD) frequently co-occurs with substance use, yet little is known about real-world patterns, motives, and contexts of use. This study characterized baseline substance use and examined day-to-day alcohol and cannabis use across 28 days of ecological momentary assessment (EMA) in adults with moderate to severe BDD with recent substance use or suicidal ideation. Eighty-seven participants (73.6% women; mean age 29.4 years, SD = 9.0, range 18-55) completed diagnostic interviews, self-report measures, and EMA surveys. At baseline, more than half (51.7%) met criteria for a current substance use disorder; among those with both diagnoses, BDD onset preceded substance use onset in 77.8% of cases. Use severity was not associated with BDD severity or impairment. Across the EMA period, 59 participants (67.8%) reported recent alcohol or cannabis use at least once. Among these participants, use was reported on a mean of 21.1% (SD = 23.1%) of surveys. Relaxation, social, and emotional coping were the most frequently endorsed primary motives. Appearance-related coping was less common, accounting for 9.8% of alcohol surveys and 14.6% of cannabis surveys on average. Use occurred primarily in leisure and social contexts; work or school was the current activity on 5.8% of surveys reporting use versus 24.2% of surveys without reported use. Recent use was not associated with concurrent suicidal ideation, but coping-motivated surveys carried three- to four-fold greater odds of suicidal desire (ORs = 3.30-4.13) than surveys reporting other motives. These real-time findings suggest coping-motivated use may be indicative of concurrent suicide risk.