Caroline Helwick

March 31, 2011

March 31, 2011 (New Orleans, Louisiana) — Body dysmorphic disorder (BDD) can be so disabling that nearly half of such patients consider suicide, according to new data presented here at the Anxiety Disorders Association of America 31st Annual Conference.

According to Katharine A. Phillips, MD, Rhode Island Hospital and Alpert Medical School of Brown University, Providence, suicidal ideation is more common with BDD than with major depression, and suicide completion rates are at least 22 times higher in the general population — findings that came as a surprise to conference delegates who attended her presentation.

"This really jumped out at me. This is 1 huge take-home message. My antenna on this will be way up now," Andrew Sweet, PsyD, a clinician in Denver, Colorado, told Medscape Medical News.

By various accounts, BDD is present in 1.7% to 2.4% of the general population and in 13% to 16% of psychiatric inpatients. It tends to occur more often in females than males.

The key clinical features of BDD are obsessional preoccupations with a body area (most often skin, hair, and nose) that average 3 to 8 hours a day and are difficult to resist or control.

Individuals with BDD demonstrate repetitive behaviors, such as mirror checking, comparing, camouflaging, excessive grooming, reassurance seeking, skin picking, and so forth. Avoidance of people and activities is common, Dr. Phillips said.

"BDD is very distressing. Functioning and quality of life can be markedly poor in these patients," she noted.

Striking Association

New data from Dr. Phillips' research and that of others show a striking association with suicidal ideation and behaviors, especially among severe cases.

In an observational study of 200 persons with BDD followed up for almost 5 years, the rate of completed suicide was 22 to 36 times higher than the general population, Dr. Phillips reported.

"The 22-fold increase is based on death certificates of confirmed suicides, while the 36-fold increase is based on cases in which suicide was deemed likely but was unconfirmed," she said.

"These markedly elevated rates are even higher than suicide rates observed in other psychiatric disorders, including major depressive disorder and bipolar disorder. This underscores the need to understand BDD better and develop more effective means of treating it," Dr. Phillips added.

She cited the following statistics, gathered from 74 moderately affected adults who took the Suicidal Behaviors Questionnaire:

  • Thought about killing yourself in the past year: 49%

  • Perceived chance of killing yourself in your lifetime: 55%

  • Perceived chance of killing yourself in the next year: 28%

  • At least some belief problems would be solved by killing yourself: 59%

"Suicidality may not be confined to clinical samples of persons with BDD," she continued.

In a recent nationwide study, 2510 persons were asked whether they had ever considered killing themselves or had attempted suicide due to appearance concerns (Psychiatr Res. 2010;178:171-175). The rates of suicidal ideation were 31.0% among those with BDD vs 3.5% among those without BDD (P < .002), whereas 22.2% vs 2.1% reported suicide attempts (P < .002).

Panic Attacks

Dr. Phillips has also evaluated the connection between BDD and panic attacks, deciphering the triggers and clinical correlates of cued attacks.

Among 76 subjects with BDD, 29% reported a history of Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition)–defined panic attacks that were triggered by BDD concerns.

These triggers included perceived scrutiny (60%), looking in the mirror (38%), bright lights (25%), and miscellaneous other conditions (20%).

A number of clinical correlates were found to be significantly associated with cued panic attacks. These included greater BDD severity (P = .001), lower social/occupational functioning (P = .001), greater suicidal ideation due to BDD (P = .002), worse psychosocial functioning (P = .006), more depressive symptoms (P = .008), not being in school due to psychopathology (P = .041), and more psychiatric hospitalizations (P = .041).

Suicidal ideation due to BDD was found in 86.4% of those with panic attacks vs 48.1% without panic attacks, and psychiatric hospitalization was reported by 54.5% vs 29.6%.

Dr. Phillips maintained that although BDD has much in common with obsessive-compulsive disorders (OCD), scores on the Brown Assessment of Beliefs Scale (BABS) show a clear distinction in thinking between the 2 groups. The BABS is a 7-item, semistructured, clinician-administered scale that measures insight/delusional thinking in a variety of mental illnesses.

In a comparison of 327 subjects with BDD and 299 with OCD, approximately 80% of BDD subjects scored in the poor or delusional range, whereas 60% of the OCD subjects scored in the good to excellent range.

On the question of whether the subject's beliefs have a psychiatric cause, almost 70% of the OCD subjects answered "definitely does," compared with just 10% of the BDD subjects. Thirty percent of the BDD subjects, in fact, answered "definitely does not."

"The individual with OCD actually realizes that even though she feels the need to check the stove a hundred times, it is unlikely that it will catch fire and burn the house down. The person with BDD, on the other hand, truly believes her body is deformed," she said.

Low Probability of Remission

"Unfortunately, there is a low probability of remission and a high probability of relapse in this disorder," she noted. It seems that the earlier the onset of BDD symptoms, the greater the likelihood of comorbid disorders, including substance abuse, Axis I disorders and Axis II disorders, and attempted suicide. Longer lifetime duration of BDD is also associated with a lower likelihood of remission, as is higher baseline severity, based on Dr. Phillips' samples.

Although no medication has been approved for the treatment of BDD, Dr. Phillips believes serotonin reuptake inhibitors (SRIs) can be effective.

She based this on open-label trials of fluvoxamine, citalopram, and escitalopram, to which some 60% to 70% of patients have responded in various studies. Fluoxetine and clomipramine have also shown efficacy in controlled studies as well. None of these agents has been associated with worsening of suicidality, she added.

"SRIs are recommended as first-line medication, including for delusional BDD. The majority of patients improve on an SRI, though high doses are often needed," she said.

"For patients who are suicidal, I integrate elements of various treatment approaches, and I always give an SRI. If they are very delusional I may start an antipsychotic, but I never use an antipsychotic alone," she added. "Better treatments are certainly needed for these patients."

'Profound' Finding

Scott L. Rauch, MD, professor of psychiatry at Harvard Medical School, Boston, Massachusetts, commented that the high suicidality reported by Dr. Phillips is a "profound" finding. "This underscores the severity of the suffering in BDD."

He further noted that studies such as these speak to the evolution of psychiatric research in general, that is, that "subelemental components and functions" within psychiatric disorders are emerging.

"The maturation seen in the BDD field maps to the evolution of how we are taking things on in psychiatry in general," he said.

Dr. Phillips disclosed receiving publication royalties and speaking honoraria from Oxford University Press and from various academic institutions and professional organizations. Dr. Rauch has disclosed no relevant financial relationships.

Anxiety Disorders Association of America (ADAA) 31st Annual Conference. Presented March 26, 2011.

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