Prevalence of body dysmorphic disorder and associated features in German adolescents: A self-report survey
Introduction
Body dysmorphic disorder (BDD) is characterized by a preoccupation with perceived defects or flaws in one's own appearance. The perceived defects are usually not or only slightly noticeable to other people. According to the DSM-5 (American Psychiatric Association, 2013), at some point during the course of the disorder, BDD sufferers engage in time-consuming repetitive behaviors (e.g., mirror checking) or mental acts (e.g., comparing one's own appearance to that of others). The preoccupation has to cause significant distress and/or impairment and is not better accounted for by concerns with body fat or weight in the context of an eating disorder. Although any body part may be the focus of concern, individuals with BDD are most frequently concerned about features related to their face or head, such as their skin, hair, or nose (e.g., Phillips et al., 2006). BDD shows high rates of lifetime comorbidity, especially with depression (75%), social anxiety disorder (SAD; 37%), and obsessive-compulsive disorder (OCD; 30%; Gunstad and Phillips, 2003). It also shares many features with social anxiety, such as avoidance of social situations, and OCD, such as excessive behaviors. This might be one of the reasons why BDD has often been discussed as “a variant of”-disorder, for example as a variant of OCD, eating disorders (ED), or somatoform disorders (Cororve and Gleaves, 2001). Previous studies on the prevalence and phenomenology of BDD in adolescents either have not reported comorbid symptoms at all (e.g., Mayville et al., 1999) or have only done so for some of the most frequent comorbid disorders, like depression or OCD (e.g., Bohne et al., 2002b; Phillips et al., 2006). Thus, it remains unclear if adults and adolescents with BDD show similar comorbidities.
In population-based studies with adults, the point prevalence rates of BDD range from 0.7% to 2.4%, based on DSM-III-R or DSM-IV criteria (Brohede et al., 2015, Buhlmann et al., 2010, Faravelli et al., 1997, Koran et al., 2008, Otto et al., 2001, Rief et al., 2006, Schieber et al., 2015). Schieber et al. (2015) additionally estimated a point prevalence of 2.9% for their sample based on DSM-5 criteria (i.e. by including the criterion of repetitive behaviors or mental acts). In their systematic review of BDD prevalence, Veale et al. (2016) calculated a weighted prevalence in community samples of adults to be 1.9%.
Many studies have examined the point prevalence of BDD based on DSM-IV criteria in young adults, mainly applying self-report measures in samples of undergraduate or college students (e.g., Bartsch, 2007; Bohne et al., 2002a, Bohne et al., 2002b; Boroughs et al., 2010; Cansever et al., 2003; Liao et al., 2010; Sarwer et al., 2005; Taqui et al., 2008). The rates range from 2.3% to 5.8%. These differences might be attributable to methodological aspects, such as sample size (ranging from N=101 to N=1041), assessment methods (e.g., self-report vs. clinician-administered interview), and the examined population (e.g., psychology students only). Therefore, in their review Veale et al. (2016) clearly accounted for the study characteristics and calculated a weighted prevalence for student samples of 3.3%. In general, even though the prevalence rates of BDD seem to vary between studies depending on the methodologies used, the systematic review by Veale et al. (2016) found overlapping confidence intervals, which indicate that there are no systematic differences in the overall prevalence of BDD between different age groups or different types of assessment measures.
Interestingly, although the onset of BDD usually happens during adolescence (Gunstad and Phillips, 2003, Perugi et al., 1997, Phillips et al., 2006, Phillips and Diaz, 1997), research on the prevalence, symptom severity, and comorbid symptoms of BDD in adolescents is limited. The only two population-based studies on the prevalence of BDD in adolescents were based on DSM-IV criteria and found prevalence rates of 2.2% (N=464; aged 14–19; Mayville et al., 1999) and 1.7% for probable and 3.4% for subthreshold BDD (N=3149; aged 12–18; Schneider et al., 2016, Schneider et al., 2017). Studies with adolescents face the challenges of both finding an adequate definition of adolescence and ensuring that younger adolescents have parental approval. The World Health Organization (WHO) defines adolescence as ages from 10 to 19 (“WHO|Adolescent development,” n.d.), but this definition has not yet been used in studies on the prevalence of BDD. Thus, based on the previous findings, it is still hard to define a reliable prevalence rate of BDD in adolescents. In addition, no studies have yet evaluated BDD prevalence in adolescents according to the newly defined DSM-5 criteria.
Besides the comparable point prevalences of BDD in adolescents and adults, Albertini and Phillips (1999) and Phillips et al. (2006) found that adolescents and adults with BDD exhibit similar clinical features and regions of concern. However, they also found that adolescents show higher levels of impairment and suicidality as well as lower levels of insight. Schneider et al. (2016) further demonstrated high levels of psychopathology, functional impairment and use of mental health services in Australian adolescents fulfilling DSM-IV BDD criteria.
In sum, more research is needed on the prevalence of BDD based on DSM-5 criteria, regions of concern, comorbid symptoms and associated features of BDD in adolescents and young adults. Extending the aforementioned DSM-IV based results, the aim of the current project was, thus, to assess self-reported DSM-5 BDD criteria, regions of concern, comorbidities, suicidality, insight and desires for cosmetic surgery in male and female German adolescents and young adults.
Section snippets
Participants
A total of 323 German individuals completed the study questionnaires. The inclusion criteria (participants between 15 and 21 years old) were not met by nine participants, who were therefore excluded from the analyses. Additionally, six participants were excluded because of incomplete data, leaving a final sample of n=308 (87.3% females), ranging from 15 to 21 years of age (M=17.1; SD=1.1; 97.7% between 15 and 19 years old). Of the final sample, 96.1% of participants were attending high school;
Prevalence of BDD and appearance concerns
The point prevalence of current BDD according to the self-report measure BDD-5 was 3.6% (n=11; 95% CI =[1.9, 5.8]). Of the individuals with BDD, 81.8% (n=9) were female. The groups (BDD vs. no-BDD) did not differ with respect to age (U (11, 297)=1581.0, p=0.85) or sex (χ2 (1)=0.31, p=0.64). Frequencies of the self-reported DSM-5 criteria for BDD are presented in Table 1.
As evident in Table 2, individuals in the overall sample were mostly concerned about their skin, their breasts, and their
Discussion
To our knowledge, this is the first study reporting prevalence rates of self-reported BDD based on DSM-5 criteria, and associated features in adolescents and young adults.
In our non-clinical adolescent sample of primarily high school students, we found a point prevalence of 3.6% for self-reported BDD based on DSM-5. Compared to the previously found 1.7% (Schneider et al., 2016) and 2.2% (Mayville et al., 1999) in community-based adolescent samples, and compared to the international
Funding information
The current project was sponsored by internal funding.
Conflict of interest
None.
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2021, Psychiatry ResearchCitation Excerpt :The disorder has a prevalence of approximately 2% among adults, and is estimated to affect between 1.9% and 2.2% of adolescents (Veale et al., 2016; Schneider et al., 2017b). Higher prevalence rates have been observed in certain groups, such as students (prevalence of 3.6%) (Möllmann et al., 2017) and older adolescent girls (prevalence of 5.6%) (Vizard et al., 2018). BDD is associated with marked reduction in psychosocial functioning, poorer quality of life, and strikingly high rates of suicidality (Phillips et al., 2006, 2005; Angelakis et al., 2016).