Body dysmorphic disorder (BDD) is a condition that is understudied, and key questions are currently unanswered. The disorder, which most commonly emerges during adolescence, can be very restricting. BDD often is undetected and untreated in youth, despite its morbidity. Research published in Journal of the American Academy of Child & Adolescent Psychiatry evaluates the prevalence, comorbidity, and psychosocial impairment that may be associated with BDD and broadly-defined appearance preoccupation present in youths and adolescents.
For this study, data from a large population-based 2017 survey, Mental Health of Children and Young People in England, was used to examine the epidemiology of BDD as well as appearance preoccupation. The survey included a sample of 9117 children and young people aged 2 to 19 years. Parents or legal guardians and their children were interviewed in-person by a researcher who assessed social and demographic factors as well as mental disorders.
Interviews were conducted with the parent only (participants aged 2 to 10 years), parents were interviewed first then asked permission to interview their children (11 to 16 years of age), or participants were interviewed first then asked permission to interview their parent or caregiver (17 to 19 years of age). Appearance preoccupation is important because it is likely more common than full-syndrome BDD, it is associated with impairment, and it is thought to be a predecessor to BDD development, meaning it can be a target during early intervention.
The 3 key objectives for this study are point prevalence of BDD among participants and any age- or sex-related effects, patterns of psychiatric comorbidity associated with BDD and appearance preoccupation, and the psychosocial impairment associated with BDD and appearance preoccupation (eg, self-harm, suicide attempt, self- and parent-reported psychosocial impact). The authors hypothesized that BDD and appearance preoccupation would be more common among adolescents than children and in females than males. Additionally, the investigators believed that BDD and appearance preoccupation may be strongly associated with internalizing disorders (anxiety-related or depressive disorders) compared with externalizing disordered (eg, oppositional defiant disorder, attention deficit/hyperactivity disorder, and conduct disorder). The investigators also speculated to observe a positive association of BDD and appearance preoccupation with all indices of impairment.
A total of 7654 children (n = 4145) and young people (n = 3509) aged 5 to 19 years were enrolled in the study. The mean age of participants is 11.18 years and 49.7% (n = 3803) were female. Additionally, most of the participants enrolled were White (75.9%, n = 5809), and their parents or guardians were homeowners (61.5%, n = 4658).
According to the findings, the prevalence of BDD among participants was approximately 1.0% (95% CI = 0.8%-1.3%) in the overall population. BDD was considered rare among children (0.1%) and significantly more common among their adolescent counterparts (1.9%). Additionally, the investigators also observed a higher prevalence among female participants (1.8%) than male (0.3%).
In the BDD model, the age by sex interaction was considered substantial, though not statistically significant (OR = 7.71, 95% CI = 0.92-64.6, p = .06). Additionally, the main effect of age group was considered significant (OR = 5.20, 95% CI = 1.05-25.8, p = .04), but not the main effect of sex (OR = 1.06, 95% CI = 0.15-7.59, p = .95). In the model of parent-reported appearance preoccupation, there was no significant age by sex interaction (OR = 1.65, 95% CI = 0.82-3.30, p = .16)) or main effect of sex (OR = 1.37, 95% CI = 0.80-2.34, p = .24); however, a main effect of age was present (OR = 2.8, 95% CI = 1.67-4.91, p < .001).
Key Takeaways
- Prevalence and Demographics of Body Dysmorphic Disorder: Body dysmorphic disorder (BDD) is relatively rare in children but much more common in adolescents, with a prevalence of 1.9%. It is more frequently observed in females (1.8%) compared to males (0.3%). BDD often emerges during adolescence and can be highly restricting, yet it remains frequently undetected and untreated in youth.
- Comorbidities and Psychosocial Impact: BDD in youths is strongly associated with other psychiatric disorders, particularly anxiety-related disorders (58.7%) and depressive disorders (31.7%). Individuals with BDD also present higher rates of self-harm and suicide attempts. The study highlights the substantial psychosocial impairment linked with BDD, emphasizing the need for early intervention and comprehensive mental health support.
- Appearance Preoccupation as a Precursor: Appearance preoccupation, which is more common than full-syndrome BDD, is associated with significant psychosocial impairment and may serve as an early indicator for BDD development. This makes early detection and intervention crucial in managing and potentially preventing the progression to BDD.
Further, approximately 19.8% of participants aged 11 to 19 years with self-reported preoccupation were also recognized as having these concerns by their parents or caregivers. The most common reported appearance concerns were body size or shape (eg, too tall or short, too thin or heavy); related to skin conditions; and other facial features (eg, nose, teeth). Most common appearance-related behaviors were comparing participants’ own appearance with others; frequently checking their appearance (eg, repeatedly looking in a mirror); excessive grooming (eg, self-tanning, styling hair); and attempt to conceal perceived flaws through make-up, wearing sunglasses, or hats and hoods.
Most young people (69.8%; 95% CI = 56.8%-80.4%) with BDD were observed to meet the diagnostic criteria for at least 1 additional psychiatric disorder, with the most common comorbidities being anxiety-related disorders (58.7%; 95% CI = 45.6%-70.8%) and depressive disorders (31.7%; 95% CI = 20.9%-44.8%). BDD was also associated with a higher frequency of any other disorder, internalizing disorders, externalizing disorders, and eating disorders, with externalizing disorders being the most common (20.6%; 95% CI = 11.9%-33.0%). The investigators noted not observing any instances of autism spectrum disorders.
Further, self-harm or suicide attempts were also common among those with BDD (self-report: 46.3%; parent-report: 35.0%). Self-reported appearance preoccupation was also associated with an elevated occurrence of self- and parent-reported self-harm and suicide attempts, according to the investigators. Participants with BDD were also more likely to seek professional help (59.7%) and to be taking a selective serotonin reuptake inhibitor (SSRI; 7.9%) or other psychotropic medication (15.9%) compared to those without BDD (professional help: 20.8%; SSRI: 7.9%; other medication: 3.2%).
According to the investigators, there are possible limitations that include parent-only reports of BDD and appearance occupation in participants younger than 12 years of age; the lack of statistical power because of the low number of BDD cases identified (n = 63); and the assessment of suicide attempts and self-harm consisting of 1 question. The investigators also acknowledge that the study’s cross-sectional design may also prevent the possibility of examining the directionality of the relationship of BDD and appearance concerns with other forms of psychopathology. Further, there is a lack of information on the percentage of young people who sought help for BDD specifically, and whether they received a professional diagnosis or treatment for BDD.
Reference
Krebs G, Clark BR, Ford TJ, Stringaris A. Epidemiology of Body Dysmorphic Disorder and Appearance Preoccupation in Youth: Prevalence, Comorbidity and Psychosocial Impairment. JAACAP. 2024. doi:10.1016/j.jaac.2024.01.017
