Body dysmorphic disorder in psychiatric outpatients: Recognition, prevalence, comorbidity, demographic, and clinical correlates

Body Dysmorphic Disorder in Psychiatric Outpatients: Recognition, Prevalence, Comorbidity, Demographic,

and Clinical Correlates MarkZ immerman and Ji l l I. MaRia

The prevalence of Body Dysmorphic Disorder (BDD), based on structured and unstructured clinical interviews, was compared in two samples of psychiatric outpatients drawn from the same practice setting. In the first sample, 500 patients were diagnosed accord- ing to a routine, unstructured clinical interview. In the second sample, 500 subjects were diagnosed accord- ing to information obtained by the Structured Clinical Interview for DSM-IV (SCID). No patient was diagnosed with BDD in the clinical sample, whereas 16 (3.2%) patients were diagnosed with BDD in the SCID sample. Compared with patients without BDD, patients with BDD received significantly more current

axis I diagnoses, and were more likely to be diagnosed with current obsessive-compulsive disorder (OCD) and social phobia. Both groups were diagnosed with major depression at similar rates. Patients with BDD, versus those without, tended to be sicker and more functionally impaired. It appears that BDD is an infre- quent disorder in an outpatient setting, which is rarely recognized when clinicians conduct their routine diagnostic interview. Although it was not usually a patient's principal reason for seeking treatment, the majority of patients with BDD in this sample wanted their treatment to address these symptoms. Copyright© 1998 by W.B. Saunders Company

B ODY DYSMORPHIC DISORDER (BDD) is a distressing and impairing preoccupation

with an imagined or slight defect in appearance.1 In a large case series of patients with BDD, Phillips et al.2,3 reported that the disorder was associated with significant impairment in academic, occupational, and social functioning. BDD was also associated with a risk of suicidal behavior (29% of patients had attempted suicide). Despite its associated suicidal risk and psychosocial impairment, many individuals are so humiliated or ashamed of their BDD symptoms that they keep their concerns secret even from clinicians who have been treating them for years. 4 The underdiagnosis of BDD has been consistently described in case series and research reports. 4-6

Studies of the prevalence of BDD in psychiatric patients suggest that the disorder is not rare. In the DSM-IV field trial for obsessive-compulsive disorder (OCD), 12% of 442 patients with OCD had comorbid BDD. 7 Two other studies found BDD rates of 15% 8 and 8% 9 in series of patients with OCD. In a study of 80 outpatients with atypical major depression, a similar percentage (13.8%) was diagnosed with BDD. 6 Other studies have found that 11% of 53 patients with social phobia 9 and 23% of 62 patients with trichotillomania had comorbid BDD. 1° These studies were limited to patients with selected axis I disorders. We are unaware of any studies that assessed the presence of BDD in an unselected sample of patients presenting for treatment in an outpatient psychiatric setting.

In the present study, a large series of outpatients

were evaluated as part of the Rhode Island Methods to Improve Diagnosis and Services (MIDAS) project. The MIDAS project was designed to examine and develop procedures to improve diagnostic practice in routine clinical settings. Patients who did and did not have BDD were compared on clinical and demographic characteristics. In addi- tion, we examined whether BDD might be underdi- agnosed in routine clinical practice by comparing the prevalence rates in two sequentially ascertained samples--one in of which BDD diagnoses were based on unstructured clinical interviews, and one in which diagnoses were made with a semistructured diagnostic interview.

METHOD

Five hundred patients were evaluated in the Rhode Island Hospital Department of Psychiatry outpatient practice. This private-practice group predominantly treats individuals who have medical insurance (including Medicare, but not Medicaid) on a fee-for-service basis, and is distinct from the hospital's outpatient residency training clinic, which predominantly serves lower income, uninsured, and medical assistance patients.

Before the initial evaluation, all patients were asked to complete a 102-item self-administered symptom questionnaire (the Psychiatric Diagnostic Screening Questionnaire [PDSQ]) as part of their initial paperwork. The clinical sample consists of 500 patients who successfully completed this questionnaire. Another 58 patients were excluded because they did not satisfactorily complete the scale (37 patients omitted > 10% of

From the Department of Psychiatry and Human Behavior, Brown University School of Medicine, Providence, RI.

Address reprint requests to Mark Zimmerman, M.D., Bayside Medical Center, 235 Plain St, Providence, R102905.

Copyright © 1998 by W.B. Saunders Company 0010-440X/98/3905-0008503.00/0

Comprehensive Psychiatry, Vol. 39, No. 5 (September/October), 1998: pp 265-270 265

266 ZIMMERMAN AND MATTIA

the items, nine patients refused, two did not speak English, one was mentally retarded, seven had visual or other physical limitations, and two were too confused or mentally ill to complete the scale).

Almost all (96%, n = 480) diagnostic evaluations were conducted by board-certified or board-eligible psychiatrists. The other evaluations were conducted by clinical nurse specialists or master's level social workers. Clinicians completed a standard- ized intake form modeled on the Initial Evaluation Form of Mezzich et al. 11 Diagnoses were based on DSM-IV criteria. 1 Patients' charts were reviewed by research assistants who recorded demographic information, axis I diagnoses, and Global Assessment of Functioning (GAF) ratings. Only definite axis I diagnoses were recorded as present; rule-out diagnoses were counted as absent.

Subsequent to the completion of the aforementioned study, the method of conducting initial diagnostic evaluations was changed. Five hundred patients were interviewed by a trained diagnostic rater who administered the Structured Clinical Inter- view for DSM-IV (SCID), 12 and the results of this interview were presented to a psychiatrist who finished the evaluation. All patients provided informed consent for participation in the study. During the course of the study, joint-interview diagnostic reliability information was collected on 17 patients. For disorders diagnosed at least two times, the kappa coefficients were as follows: major depressive disorder (MDD) (K = 1.0); dysthymic disorder (K = 1.0); bipolar disorder (K = 1.0); depressive disorder, not otherwise specified (NOS) (K = .45); adjustment disorder (K = .45); panic disorder (K = 1.0); social phobia (K = .87); OCD (K = 1.0); specific phobia (K = 1.0); generalized anxiety disorder (GAD) (K = .64); posttranmatic stress disorder (PTSD) (K = 1.0); and anxiety disorder NOS (K = . 19). None of the 17 patients was diagnosed with BDD.

Towards the end of the clinical study, and throughout the SCID study, patients were given a booklet of questionnaires to complete at home and return by mail Fifty-one patients in the clinical sample and 275 patients in the SCID sample returned the booklet of questionnaires. To examine the clinical similarity of the clinical and SCID samples, the two groups of patients were compared on self-report symptom measures of bulimia (Eating Disorder Inventory Bulimia Subscale)13; social phobia (Brief Fear of Negative Evaluation Scale, 14 Fear Questionnaire-Social Phobia Subscale)15; agoraphobic fears (Fear Questionnaire- Agoraphobia Subscale, 13 Social Phobia and Anxiety Inventory Agoraphobia Subscale)16; posttraumatic stress (Posttraumatic Stress Disorder Scale)17; obsessive-compulsive behavior (Obses- sive Compulsive Scale)IS; cognitions common in generalized anxiety (Penn State Worry Scale)19; anxiety symptoms common in panic attacks (Beck Anxiety Inventory)2°; alcohol use (Michi- gan Alcohol Screening Test)21; chug use (Drug Abuse Screening Test) 22, hypochondriasis (Whitely Index)23; and somatization (Somatic Symptom Index). 24,25 These scales have been com- monly used in research, and their reliability and validity have been well established.

The core of the diagnostic evaluation was the January 1995 DSM-IV patient version of the SCID. 12 The axis I version of the SCID covers seven DSM-IV sections: (1) mood disorders (MDD, bipolar disorder, dysthymia, depressive disorder NOS, mood disorder due to a general medical condition, and substance- induced mood disorder); (2) psychotic disorders (schizophrenia, schizophreniform disorder, delusional disorder, schizoaffective

disorder, brief psychotic disorder, and psychotic disorder NOS); (3) substance use disorders (abuse and dependence of alcohol, sedative-hypnotics, cannabis, stimulants, opioids, cocaine, hallu- cinogens, inhalents, phenylcyclidine, and polydrug); (4) anxiety disorders (panic disorder with and without agoraphobia, agoraphobia without history of panic disorder, social phobia, specific phobia, OCD, PTSD, acute stress disorder, GAD, and anxiety disorder NOS); (5) somatoform disorders (somatization disorder, pain disorder, undifferentiated somatoform disorder, hypochondriasis, and body dysmorphic disorder); (6) adjustment disorders; and (7) eating disorders (anorexia nervosa, bulimia nervosa, and binge-eating disorder). The SCID does not cover childhood, cognitive, factitious, dissociative, sexual and gender identity, sleep, and impulse-control disorders, or other conditions that may be the focus of clinical attention. However, information from the overview at the beginning of the interview could be used to diagnose these other disorders.

The DSM-IV version of the SCID includes a BDD module in the somatoform disorders section. In the overview of this section, BDD is screened for by the question "Some people are very bothered by the way they look. Is this a problem for you?" The BDD module assesses the level of preoccupation with appearance, and the impairment and/or distress caused by the preoccupation. For patients with BDD, we inquired whether the BDD symptoms were a reason for currently seeking treatment. Whether BDD was the principal or additional diagnosis was based on the patients' primary reason for seeking treatment.

In the present report, the prevalence rates of current DSM-IV disorders were compared for patients with and without the diagnosis of BDD. Although DSM-IV includes a partial remission specifier only for the mood and substance use disorders, we adopted this specifier for all disorders. For example, someone who met DSM-IV criteria for PTSD 5 years ago but at the time of the evaluation was bothered by a subthreshold number of criteria, or someone who was bingeing and purging only once per week during the past 6 months but who met criteria for bulimia nervosa 6 months before the evaluation, would be diagnosed with the disorder in partial remission. In the present analyses, partial remissions were considered as present.

Supplementing the SCID interview, were items from the Schedule for Affective Disorders and Schizophrenia (SADS) 26 on current and adolescent social functioning, and the amount of time employed during the past 5 years. The Clinical Global Index of depression severity 27 was rated on all patients.

For continuously distributed variables, t tests were used to compare patients who did and did not have BDD. Pooled variance estimates were used when the variances in the BDD- positive and BDD-negative groups significantly differed, otherwise separate variance estimates were used. Categorical variables were compared by X 2 analysis, or Fisher's exact test if the expected value in any cell of a 2 × 2 table was less than 5.

RESULTS

T h e d e m o g r a p h i c c h a r a c t e r i s t i c s o f t he t w o

s a m p l e s w e r e s i m i l a r (Tab le 1). T h e m a j o r i t y o f

b o t h s a m p l e s w e r e w h i t e , f e m a l e , h i g h s c h o o l

g r a d u a t e s , a n d m a r r i e d o r s ing le . T h e r e w e r e n o

s ign i f i c an t d i f f e r e n c e s b e t w e e n the t w o s a m p l e s in

t he i r d e m o g r a p h i c cha r ac t e r i s t i c s . P a t i e n t s in t h e

BODY DYSMORPHIC DISORDER

Table 1. Demographic Characteristics of Clinical and SClD Samples

Clinical SCID (n = 500) (n = 500)

% No. % No. ×2 p

Sex

Female 62.6 313 60.4 302 0.5 NS

Male 37.4 187 39.6 198

Race White 94,4 472 91.6 458 3.0 NS

Non-white 5.6 28 8.4 42 Education*

Less than high

school graduate 9.3 40 11.8 59 3,6 NS

High school graduate 27.1 116 22.4 112

At least some college 63,6 272 65.8 329

Marital status

Married 49.4 247 45.2 226 11.0 NS

Living together 4.2 21 2.4 12

Widowed 3.8 19 1.8 9

Separated 5.8 29 7.2 36

Divorced 13.2 66 14.0 70

Never married 23.6 118 29.4 147

A g e t ( m e a n ± S D ) 39.6_+ 13.1 38 .7± 13.3 t = t.0 NS

Abbreviations: SCID, Structured Clinical Interview for DSM- IV, NS, not significant.

*Educational status on 72 clinical subjects was missing. rage was compared by ttest.

clinical and SCID samples were compared on the self-report symptom-severity measures, and there were no significant differences between the groups. Thus, the SCID and clinical patient samples were similar on self-report measures of symptom severity and demographic characteristics.

Clinical Recognition and Prevalence of BDD

No patient was diagnosed with BDD in the clinical sample, whereas 16 patients were diagnosed with BDD in the SCID sample (0.0% v 3.2%, X 2 = 16.3, P < .001). BDD was the principal diagnosis for three (0.6%) patients, and was an additional diagnosis for 13 (2.6%) patients. The principal diagnoses in these 13 patients were MDD (n = 7), social phobia (n = 1), panic disorder with agoraphobia (n = 1), PTSD (n = 1), dysthymic disorder (n = 1), and eating and depressive disorder NOS (1 each).

Eleven (68.8%) of the 16 BDD patients indicated their BDD symptom(s) was one of the reasons they were seeking treatment. Of the 13 patients who had BDD as an additional, comorbid diagnosis, eight (61.5%) wanted treatment for these symptoms.

267

Demographic Correlates of BDD

Patients with BDD were significantly younger than the non-BDD patients (Table 2). Neither sex nor race was significantly associated with BDD status. Compared with patients without BDD, patients with BDD were twice as likely to have never married (56.3% v 28.5%; Fisher's exact test, P = .02), and nearly four times less likely to have graduated from college (6.3% v 24.0%; Fisher's exact test, P = .08). However, these findings need to be interpreted cautiously, because the overall tests for marital status and education were not significant.

Diagnostic Comorbidity

Patients with BDD received more axis I diagnoses than the patients without BDD (3.44 ___ 0.89 v 2.22 _+ 1.46, t = 3.30, P < .001), and they were significantly more likely to have three or more disorders other than BDD (87.5% v 36.4%, ×2 = 17.2, P < .001). Looking at the specific axis I diagnoses, BDD patients were significantly more likely to have current diagnoses of social phobia and OCD (Table 3). The most frequent diagnosis in the BDD patients was major depression; however,

Table 2. Demographic Characteristics of 500 Psychiatric Outpatients With and Without BDD

BDD Present BDDAbsent (n = 16) (n = 484)

% No. % No. x 2 P

Sex

Female 75.0

Male 25.0 Race

White 93.8

Non-white 6.3

Education*

Less than high

school graduate 12.5

High school

graduate 18.8 3

Some college 62.5 10 College graduate 6.3 1

Marital status

Married 31.3 5 Living together 6.3 1

Widowed 0 0 Separated 6.3 1 Divorced 0 0

Never married 56.3 9

Ages (mean ± SD) 31.6 _+ 10.8

12 59.9 290 1.47 NS 4 40.1 194

15 91.5 443 t NS

1 8.5 41

2 11.8 57 3.76 NS

22.5 109

41.7 202

24.0 116

45.7 221 8.42 NS 2.3 11 1.9 9 7.2 35

14.5 70

28.5 138

39.0 ± 13.3 t = 2.18 <.05

*Educational status on 72 clinical subjects was missing. tFisher's exact test,

rAge was compared by ttest.

268

Table 3. Percent of Current DSM-IV Axis I Di=orders in 500 Psychiatric Outpatients With and Without Body Dysmorphic

Disorder

BDD Present BDDAbsent (n = 16) (n = 484) ×2 % No. % No. (Pvalue)

Mood disorders Major depression 68.8 11 54.3 263 NS Dysthymic disorder 18.8 3 7.0 34 NS Bipolar I disorder 0 0 3.5 17 NS Bipolar II disorder 6.3 1 3.9 19 NS Depressive disorder

NOS 6.3 1 8.5 41 NS Depression due to

GMC 0 0 1.2 6 NS Anxiety disorders

Panic disorder 6.3 1 4.8 23 NS Panic disorder w/ago-

raphobia 25.0 4 14.5 70 NS Agoraphobia w/o his-

tory of panic 6.3 1 1.0 5 NS Social phobia 68.8 11 27.7 134 .00095* Specific phobia 25.0 4 9.9 48 NS Posttraumatic stress

disorder 31.3 5 19.6 95 NS Generalized anxiety

disorder 18.8 3 9.3 45 NS Obsessive-compulsive

disorder 37.5 6 8.3 40 .0017" Anxiety disorder NOS 12.5 2 15.7 76 NS

Substance use disorders Alcohol abuse/depen-

dence 6.3 1 7.0 34 NS Drug abuse/depen-

dence 6.3 1 4.8 23 NS Any substance use dis-

order 6.3 1 9.5 46 NS Any eating disorder 18.8 3 7.4 36 NS Any psychotic disorder 0 O 3.3 16 NS Any somatoform dis-

order 6.3 1 5.2 25 NS Any impulse control dis-

ordert 0 0 5.1 20 NS Adjustment disorders 0 0 5.2 25 NS Attention deficit disor-

ders 0 0 3.9 19 NS

Abbreviations: NOS, not otherwise specified; GMC, General Medical Conduction; NS, nonsignificant.

*Fisher's exact test. t lmpulse control disorders were assessed in 409 patients.

BDD patients were no more likely to have MDD than were patients without BDD.

Reversing the conditional probabilities presented in Table 3 and examining the frequency of BDD in patients with different axis I disorders, we found that for disorders diagnosed in at least 10 patients, the patients with OCD were the most

ZlMMERMAN AND MA'I-I'IA

likely to have BDD (13.0% of 46 patients). This was followed by dysthymic disorder (8.1% of 37 patients), social phobia (7.6% of 145 patients), and GAD (6.3% of 48 patients).

Illness Severity and Suicidality

The data in Table 4 indicate that the BDD patients were a more severely ill group. They were rated significantly lower on the GAF, indicating that their overall level of functioning was poorer. On the SADS rating of best level of social functioning during the 5 years before the interview, the BDD patients were rated significantly higher (indicating poorer functioning). Looking at this rating categorically, twice as many patients with BDD had poor social functioning (50.0% v 26.9%; Fisher's exact test, P---.05). Across all patients, the BDD patients were more severely depressed, despite a lack of difference in prevalence rate of major depression. The patients with BDD were not significantly more likely to have a lifetime history of suicide attempts or psychiatric hospitalization.

DISCUSSION

Approximately 3% of psychiatric outpatients were diagnosed with BDD when they were interviewed with a semistructured diagnostic interview. In the patient series collected before the SCID was included in the diagnostic evaluation process, no patient was diagnosed with BDD. This is consistent with previous clinical observations that BDD is an underrecognized disorder, and raises questions re- garding the reliability of diagnosing BDD in clinical settings. We are not aware of any studies examining the reliability of diagnosing BDD in clinical settings. Given its low prevalence, it will be difficult to establish high reliability for this diagnosis.

We found that the BDD patients were more severely ill than the non-BDD patients, as has been reported by other investigators. 6 Their GAF scores were lower, they more frequently had multiple axis I disorders, they were more severely depressed, and they had poorer social functioning. In case series descriptions of BDD patients, very high percent- ages of patients have never been married. 2,3,28 Consistent with this, we found that more BDD than non-BDD patients had never been married.

Previous research has examined diagnostic comorbidity from two perspectives---one approach has been to examine the frequency of axis I

BODY DYSMORPHIC DISORDER 269

Table 4. Clinical and Psychosocial Correlates of BDD

BDD Present (n = 16) BDD Absent (n = 484) (mean +_ SD) (mean -+ SO) t P

GAF 45.75 _+ 11.32

Clinical global impression 3.00 ÷ 1.03

No. of current DSM-IV diagnoses 3.44 + 0.89

SADS

Social func t ion ing- -pas t 5 years 3.81 _+ 1,56

Social func t ion ing- -ado lescence 3.19 -+ 0.98

-time out o f wo rk - -pas t 5 years 3.00 -+ 2.34

At least 1 l i fet ime hospital izat ion 18.8% (n = 3)

At least 1 l i fet ime suicide at tempt 18.8% (n = 3)

52.38 _+ 11.84 2.21 <.05

2.32 _+ 1.22 2.19 <.05

2.23 _+ 1.46 3.30 <.001

2.92 _+ 1.33 2.64 <.01

3.04 _+ 1.16 0.50 NS

2.49 _+ 2.10 0.94 NS

23.1% (n = 112) * NS

19.6% (n = 95) * NS

Abbreviat ion: NS, nonsignif icant.

*Fisher's exact test.

disorders in patients with BDD, and the other approach has been to examine the frequency of BDD in patients with particular axis I disorders. In the 50 BDD patients evaluated by Hollander et al. 2s OCD and depression were the most frequent comorbid lifetime conditions, each of them present in more than two thirds of the patients. Phillips et al. 2 similarly found that depression, OCD, and social phobia were the most frequent lifetime disorders in their case series of 100 BDD patients.

Consistent with the findings from these case series, we found that mood disorders were the most frequent diagnoses in the patients with BDD. However, depression was equally common in the patients without BDD. Thus, although many patients with BDD present with a chief complaint of depression, we did not find evidence that BDD is a risk factor beyond that of other psychiatric disorders for having MDD.

Although BDD is classified in DSM-IV as a somatoform disorder, several researchers have sug- gested that it is more appropriately conceptualized as an OCD spectrum disorder. 4,5,8,29-31 The link between BDD and OCD is based on phenomeno- logic similarities (both disorders are characterized by distressing, intrusive thoughts and repetitive behaviors), as well as similar sex ratios, age of onset, chronic course of illness, high comorbidity with each other, and possible preferential response to serotonin reuptake inhibitors. In the present series, BDD status was significantly associated with the diagnosis of OCD, although less than half of the BDD patients had comorbid OCD.

The other method of examining diagnostic comorbidity has been to assess the prevalence of BDD in patients with specific axis ! disorders. Three studies of OCD found rates of BDD ranging from 8% to

15%. The 13% rate found in the present study is consistent with these studies. Brawman-Mintzer et a l . 9 reported that 11% of 54 patients with social phobia had BDD, a prevalence rate that is slightly higher than the 7.6% rate found in the present study. They found that no patient with GAD, and only one of the 47 patients with panic disorder, had BDD. We also found lower rates of BDD in the patients with GAD and panic disorder, compared with the patients with OCD and social phobia.

In highlighting the clinical significance of BDD, Phillips 4 has noted that patients with BDD are at high risk for suicidal behavior. We found that one fifth of BDD patients had a lifetime history of suicidal behavior, but this was no different than the rate of suicidal behavior in the patients without BDD. The suicide attempt rate was lower than the 29% rate reported by Phillips. It is possible that the patients described in Phillips' case series have prototypic, especially severe variants of the disorder. In studies that ascertain BDD in a heteroge- neous patient sample, the identified cases may be less representative of classic BDD, and thus, less severe.

In conclusion, this is the first study that has examined the prevalence of BDD in a heteroge- neous sample of psychiatric outpatients presenting for treatment. The results suggest that BDD is a relatively rare disorder, and when it is present, it is usually not the principal reason for seeking treatment. However, BDD is associated with increasing severity of psychopathology and functional impairment, and most patients with BDD want their treatment to address their BDD concerns. The samples in this study were drawn from a large, general adult-outpatient private-practice setting in which the most common presenting problems were

270 ZIMMERMAN AND MAI-rlA

m o o d and anx ie ty d isorders . R h o d e I s l and has a

s t rong c o m m u n i t y m e n t a l hea l th cen te r n e t w o r k

that t reats m o s t o f the ch ron ica l ly men ta l l y ill

pat ients , and this accounts , in part , fo r the low

p r e v a l e n c e ra tes of p sycho t i c d isorders . In addi t ion ,

the prac t ice does not h a v e a specia l i s t in the

t r ea tmen t o f subs t ance use d isorders ; thus , pa t ien ts

w i th a p r i m a r y subs t ance use p r o b l e m are inf re-

quen t ly encoun te red . It wi l l be i m p o r t a n t to deter-

m i n e i f ou r f indings r ega rd ing the p r e v a l e n c e and

cor re la tes o f B D D genera l i ze to o the r se t t ings wi th

different demographic and d iagnos t i c character is t ics .

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Body dysmorphic disorder in psychiatric outpatients: Recognition, prevalence, comorbidity, demographic, and clinical correlates