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 RESEARCH ARTICLE

A comparison of comorbidity in body dysmorphic disorder and obsessive-compulsive disorder

Rait Tükel, MD

Istanbul University, Istanbul Faculty of Medicine, Department of Psychiatry, Istanbul, Turkey

Aysu Kıvrak Tihan, MD

Istanbul University, Istanbul Faculty of Medicine, Department of Psychiatry, Istanbul, Turkey

Nalan Öztürk, MD

Istanbul University, Istanbul Faculty of Medicine, Department of Psychiatry, Istanbul, Turkey

BACKGROUND: The aim of this study is to compare 3 groups of patients with body dysmorphic disorder (BDD), obsessive-compulsive disorder (OCD), and comorbid BDD and OCD with respect to clinical characteristics and to study their similarities and differences.

METHODS: Twenty-nine patients diagnosed with BDD, 20 diagnosed with comorbid BDD/OCD and 49 diagnosed with OCD were included in the study. Patients with BDD, comorbid BDD/OCD, and OCD were compared in terms of demographic and clinical variables and scores obtained from various scales.

RESULTS: Patients in the comorbid BDD/OCD and OCD groups tended to have higher anxiety scores than in BDD group. Any depressive disorder was more common in the comorbid BDD/OCD and OCD groups than in the BDD group. A significantly higher proportion of patients with BDD/OCD had any anxiety disorder than those with BDD. Subjects with BDD were significantly more likely than subjects with OCD to have narcissistic and avoidant personality disorders and any Axis II personality disorder. Finally, the rate of any cluster B personality disorder was higher in the BDD and BDD/OCD groups than in the OCD group.

CONCLUSIONS: Despite the similarities between BDD and OCD, these disorders appear to have different aspects especially on psychiatric comorbidity.

KEYWORDS: body dysmorphic disorder, obsessive-compulsive disorder, comorbidity, personality disorders

ANNALS OF CLINICAL PSYCHIATRY 2013;25(3):210-216

  INTRODUCTION

In DSM-IV, body dysmorphic disorder (BDD) is defined as a preoccupation with an imagined or slight defect in appearance that causes clinically significant distress or impairment in functioning.1 BDD historically has been linked with obsessive-compulsive disorder (OCD). Early in the 20th century, Kraepelin stated that dysmorphophobic symptoms must be classified as compulsive neurosis because they are persistent and ego-dystonic; similarly, Janet classified this condition as a syndrome similar to OCD in that they present “obsessions with shame of the body.”2

BDD is widely considered an “OCD-spectrum disorder” because of its similarity with OCD in terms of phenomenology, demographic features, prognoses of the disease, comorbidity, family history, and treatment response.3-9 In DSM-5, BDD has been moved to a new chapter on obsessive-compulsive and related disorders.10

Mental preoccupations in BDD structurally resemble OCD obsessions in that the repetitive intrusive thoughts accompanied by anxiety and distress usually are difficult to resist or control.6 Similar to OCD, BDD patients engage in ritualistic behaviors in response to their mental preoccupations. Such behaviors include checking the perceived defected body part in the mirror, concealing this part, or comparing it with the same part of other people’s bodies for reassurance.2,6,11,12

Clinical observations and study results demonstrate that patients with BDD had significantly poorer insight than those with OCD and were more likely to be delusional.7,13-17 Although OCD and BDD patients showed some other differences in clinical features,11,13,15,17,18 there is no consensus on the similarities and differences of the 2 disorders in terms of psychiatric comorbidity.

Two studies have compared demographic and clinical characteristics between patients with OCD, BDD, and comorbid BDD/OCD.11,17 Frare et al11 compared demographic characteristics, clinical features, and psychiatric comorbidity in patients with OCD (n = 79), BDD (n = 34), or comorbid BDD/OCD (n = 24) who were diagnosed using DSM-III-R criteria, and found that the 3 groups showed significant differentiation in the presence of comorbid bulimia nervosa, alcohol-related, and substance-use disorders with BDD/OCD patients showing the highest rate and OCD the lowest. Authors also reported that BDD/OCD patients had more comorbid bipolar II disorder and social phobia than in the other 2 groups, while generalized anxiety disorder (GAD) was observed more frequently in OCD patients. Another study17 compared demographic and clinical features of patients with OCD (n = 210), BDD (n = 45), or comorbid BDD/OCD (n = 40) diagnosed using DSM-IV criteria and found that patients with BDD had significantly poorer insight and more lifetime suicidal ideation, major depressive disorder, and substance use disorders than patients with OCD. In the same study,17 the comorbid BDD/OCD group was shown to have greater morbidity than patients with OCD or BDD in a number of domains.

The aim of the present study is to investigate the similarities and differences between OCD and BDD with respect to demographic and some clinical features including comorbidity. Based on previous findings and an approach that OCD is an anxiety disorder, we hypothesized that patients with OCD (OCD-only or comorbid BDD/OCD) would be more likely to have any Axis I anxiety disorder than subjects with only BDD. On the other hand, based on our clinical experience, we also hypothesized that subjects with BDD (BDD only or comorbid BDD/OCD) would be more likely to have Axis II personality disorders, especially avoidant and narcissistic personality disorders than patients with only OCD. Accordingly, the patients grouped as BDD, comorbid BDD/OCD, and OCD were compared on the following dimensions: 1) demographic characteristics; 2) levels of anxiety and depression; and 3) presence of additional Axis I and Axis II disorders.

  METHODS

Subjects

Forty-nine patients with OCD, 29 with BDD, and 20 with comorbid OCD/BDD were recruited. OCD and BDD were diagnosed by the Structured Clinical Interview for DSM-IV/Clinical Version (SCID-I/CV).19

All patients were seen in Anxiety Disorders Outpatient Clinic of the Psychiatry Department of Istanbul Faculty of Medicine between 2004 and 2009. The institutional review board of Istanbul Faculty of Medicine at Istanbul University approved the study. After full explanation of the procedures, all the participants gave written informed consent. This study adheres to the Declaration of Helsinki.

All patients were free from psychotropic drugs for at least 6 weeks before the recruitment. Exclusion criteria were: 1) any serious concomitant general medical condition or neurologic disease; 2) history of medical disorders that may have a causal relationship with OCD; 3) Yale-Brown Obsessive Compulsive Scale (Y-BOCS)20,21 score ≤15 for OCD patients.

Clinical measures

All patients were administered the Hamilton Rating Scale for Anxiety (HRSA)22 and the Hamilton Rating Scale for Depression (HRSD).23

A semi-structured interview form developed by the investigators was used to determine the sociodemographic characteristics of the patients and the clinical features of the disorder. The SCID/CV and the Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II)24 were used to diagnose Axis I and Axis II disorders. All SCID/CV and SCID-II interviews were performed by trained psychiatrists.

Statistical analysis

Statistical analyses were conducted by using SPSS 11.5 for Windows. In the comparisons between groups, chi-square test was used for categoric variables. Fisher exact test was employed when necessary. Comparison of continuous variables among 3 groups was analyzed using the one-way ANOVA test. Post hoc comparisons were made with Bonferroni test. Effect sizes are reported as phi for chi-square analyses and partial eta squared for 1-way ANOVA.

To diminish the possibility of type I error, we used—as Phillips et al17 and Garyfallos et al25—a partial alpha correction of P < .01 to determine statistical significance. A full Bonferoni correction was not applied given that this approach tends to be overly conservative.17,25,26 The P values from P = .01 to P < .05 were considered to constitute a trend.

  RESULTS

The demographic characteristics of the OCD, BDD, and comorbid BDD/OCD groups are listed in TABLE 1. There were no significant differences among the groups in terms of age, sex ratios, and ratios of married patients (TABLE 1). Years of education were higher in the BDD group than in the OCD group, whereas there was no significant difference in the same variable when we compared the BDD/OCD group with the BDD and OCD groups (TABLE 1).


TABLE 1

Demographic characteristics and mean scores on measures of anxiety, depression, and obsessive-compulsive symptomatology

  BDD
(n = 29)
BDD/OCD
(n = 20)
OCD
(n = 49)
     
  n (%) n (%) n (%) φ χ2 P
Sex (female) 18 (62.1) 13 (65.0) 27 (55.1) 0.09 0.72 .70
Marital status (married) 5 (17.2) 3 (15.0) 17 (34.7) 0.21 4.38 .11
  Mean (SD) Mean (SD) Mean (SD) Partial eta squared F P
Age at assessment (y) 25.48 (7.06) 25.85 (7.04) 28.12 (9.42) 0.02 1.10 .34
Years of education 12.62a (3.21) 11.80a,b (3.04) 9.98b (3.52) 0.12 6.20 .003
Age at onset of BDDc vs OCDd (y) 18.28 (6.18) 16.50 (6.53) 21.18 (8.24) 0.07 3.30 .04
Duration of BDDc vs OCDd (m) 26.55a (41.56) 86.15b (87.10) 84.58b (64.05) 0.15 8.49 <.001
HRSD 12.48 (8.1) 14.55 (8.2) 13.41 (8.9) 0.009 0.44 0.64
HRSA 13.14 (9.34) 19.53 (9.01) 18.92 (9.70) 0.08 3.94 0.02
Y-BOCS   25.29 (5.96) 25.22 (6.78)      
a,bMeans in a row with different subscript letters indicate significant differences (P < .01) between the 2 groups according to the Bonferroni post hoc test.
cBDD with and without OCD groups.
dOCD-only group.

BDD: body dysmorphic disorder; HRSA: Hamilton Rating Scale for Anxiety; HRSD: Hamilton Rating Scale for Depression; OCD: obsessive-compulsive disorder;
SD: standard deviation; Y-BOCS: Yale-Brown Obsessive Compulsive Scale.

No significant difference in age at disease onset was found between the 3 groups (TABLE 1). The duration of illness was significantly higher in the comorbid BDD/OCD and OCD groups than in the BDD group (TABLE 1).

Scores obtained from several scales are listed in TABLE 1. HRSA scores tended to be higher in the OCD and BDD/OCD groups than in the BDD group, yet there was no significant difference among the 3 groups in HRSD scores (TABLE 1).

Comorbidity rates in the 3 groups are listed in TABLE 2. The BDD/OCD group had significantly higher rate of major depression compared with the BDD group, whereas there was no significant difference in terms of the presence of major depression in the OCD group compared with the BDD and BDD/OCD groups (TABLE 2). Dysthymia was seen more frequently in the OCD group than in the BDD group, whereas there was no significant difference in presence of dysthymia among the BDD/OCD and the other 2 groups (TABLE 2).


TABLE 2

Frequency and percentage of additional current Axis I diagnoses in BDD, comorbid BDD/OCD, and OCD patients

  BDD
(n = 29)
BDD/OCD
(n = 20)
OCD
(n = 49)
     
  n (%) n (%) n (%) φ χ2 P
Depressive disorders 5a (17.2) 12b (60.0) 25b (51.0) 0.34 11.50 .003
  Major depression 4a (13.8) 10b (50.0) 15a,b (30.6) 0.28 7.50 .02
  Dysthymia 1a (3.4) 2a,b (10.0) 13b (26.5) 0.28 7.84 .02
Anxiety disorders 5a (17.2) 12b (60.0) 19a,b (38.8) 0.31 9.49 .009
  Social phobia 2 (6.9) 6 (30.0) 8 (16.3) 0.22 4.63 .099
  Specific phobia 3 (10.3) 2 (10.0) 8 (16.3) 0.09 0.80 .67
  PD with or without agoraphobia 0 (0.0) 2 (10.0) 5 (10.2) 0.18 3.17 .21
  Agoraphobia without history of PD 0 (0.0) 0 (0.0) 2 (4.1) 0.14 2.04 .36
  GAD 1 (3.4) 2 (10.0) 2 (4.1) 0.11 1.26 .53
Other Axis I disorders            
  Somatization disorder 0 (0.0) 0 (0.0) 2 (4.1) 0.14 2.04 .36
  Hypochondriasis 0 (0.0) 0 (0.0) 2 (4.1) 0.14 2.04 .36
  Alcohol abuse 1 (3.4) 1 (5.0) 1 (2.0) 0.07 0.44 .80
a,bMeans in a row with different subscript letters indicate significant differences (P < .01) between the 2 groups according to the Bonferroni post hoc test.

The Structured Clinical Interview for DSM-IV/Clinical Version (SCID-I/CV) were used to diagnose the Axis I disorders.
BDD: body dysmorphic disorder; GAD: generalized anxiety disorder; OCD: obsessive-compulsive disorder; PD: panic disorder.

Patients with OCD or comorbid BDD/OCD were significantly more likely than those with BDD to have any depressive disorder (TABLE 2). Partly consistent with our hypothesis, a significantly higher proportion of patients with comorbid BDD/OCD had any anxiety disorder compared with patients with BDD, whereas there was no significant difference in the presence of any anxiety disorder between the OCD group and the other 2 groups (TABLE 2).

As hypothesized, patients with BDD were significantly more likely than patients with OCD to have narcissistic and avoidant personality disorders, and any Axis II personality disorder (TABLE 3). Patients with BDD and BDD/OCD were more likely to have histrionic personality disorder than patients with OCD (TABLE 3). The 3 groups of patients were similar regarding the presence of other Axis II disorders. The evaluation of personality disorders revealed that cluster B personality disorders were significantly more common in the BDD and BDD/OCD groups than in the OCD group, whereas the 3 groups of patients were similar in presence of cluster A and cluster C personality disorders (TABLE 3).


TABLE 3

Frequency and percentage of Axis II personality disorders in BDD, comorbid BDD/OCD and OCD patients

  BDD
(n = 29)
BDD/OCD
(n = 20)
OCD
(n = 49)
     
  n (%) n (%) n (%) φ χ2 P
Cluster A 10 (34.5) 8 (40.0) 10 (20.4) 0.19 3.38 .19
  Paranoid 9 (31.0) 8 (40.0) 7 (14.3) 0.25 6.03 .49
  Schizoid 2 (6.9) 0 (0.0) 5 (10.2) 0.15 2.23 .33
  Schizotypal 2 (6.9) 1 (5.0) 1 (2.0) 0.11 1.15 .56
Cluster B 16a (55.2) 13a (65.0) 11b (22.4) 0.38 14.16 .001
  Antisocial 0 (0.0) 1 (5.0) 0 (0.0) 0.20 3.94 .14
  Borderline 8 (27.6) 5 (25.0) 5 (10.2) 0.21 4.41 .11
  Histrionic 11 (37.9) 8 (40.0) 6 (12.2) 0.31 9.10 .01
  Narcissistic 9a (31.0) 6a,b (30.0) 3b (6.1) 0.32 9.81 .007
Cluster C 25 (86.2) 14 (70.0) 30 (61.2) 0.24 5.46 .065
  Avoidant 19a (65.5) 10a,b (50.0) 16b (32.7) 0.29 8.09 .017
  Dependent 5 (17.2) 6 (30.0) 4 (8.2) 0.23 5.43 .069
  Obsessive-compulsive 11 (37.9) 8 (40.0) 21 (42.9) 0.04 0.19 .91
Axis II disorders (any) 28a (96.6) 18a,b (90.0) 33b (67.3) 0.34 11.36 .003
a,bMeans in a row with different subscript letters indicate significant differences (P < .01) between the 2 groups according to the Bonferroni post hoc test.

Axis II disorders, in which minimum expected count is less than 2, were excluded from the table.
The Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II) was used to diagnose the personality disorders.
BDD: body dysmorphic disorder; OCD: obsessive-compulsive disorder.

  DISCUSSION

Our results indicate that OCD and BDD share important similarities and some notable differences. Whereas reports by Phillips et al,27 Frare et al,11 and Conceição Costa et al13 have suggested that patients with BDD were less likely to be married, we found that the BDD, comorbid BDD/OCD, and OCD groups were similar with regard to age, sex, and marital status. These results are consistent with those of Marazziti et al15 and Phillips et al.17 In contrast to the findings of Nakata et al18 and Frare et al11 that found lower educational levels in the BDD/OCD group than in the OCD group, in our study the BDD group had higher educational years compared with the OCD group. Age of disease onset was earlier in the comorbid BDD or BDD/OCD groups than the OCD group.11 Conceição Costa et al13 found that OCD/BDD patients had an earlier onset of obsessive-compulsive symptoms compared with OCD-only patients. In contrast with these findings, we found no difference in age at disease onset between the groups.

Phillips et al17 found no difference in duration of illness between BDD and OCD patients. In contrast, duration of illness was significantly higher in the comorbid BDD/OCD and OCD groups than in the BDD group in our study.

Although McKay et al7 found no significant difference was found for depression and anxiety, Phillips et al17 reported that depressive symptoms were significantly more severe for patients with comorbid BDD/OCD than for those with OCD or BDD and Conceição Costa et al13 also found that OCD/BDD patients had more severe depression and anxiety symptoms than OCD-only patients. We found that whereas there was no significant difference among the groups in HRSD scores, HRSA scores were higher in the BDD/OCD and OCD groups than in the BDD group.

Frare et al11 found that the BDD, OCD, and comorbid BDD/OCD groups were similar in the presence of major depression, panic disorder/agoraphobia, and anorexia nervosa, whereas comorbid BDD/OCD group was more likely to have comorbid bipolar II disorder, social phobia, and substance-use disorders compared to the other 2 groups. However, GAD was observed more frequently in the OCD group than in the other 2 groups in the same study.11 Phillips et al17 demonstrated that patients diagnosed with BDD were more likely to have lifetime major depressive disorder, dysthymia, and any mood disorder as well as a substance use disorder than those diagnosed with OCD. Nakata et al18 found that the BDD/OCD group differed from the OCD group in higher number of comorbid psychiatric disorders including anxiety disorders. In a study by Conceição Costa et al,13 the OCD/BDD group showed higher rates of mood, anxiety, and eating disorders, hypochondriasis, and Tourette syndrome compared with OCD-only group. Our results show that patients with only BDD have lower rates of major depression, compared with those with BDD/OCD, implying that the likelihood of developing major depression increases especially when OCD accompanies BDD. The frequency of any depressive disorder was found to be significantly higher in the BDD/OCD and OCD groups than in the BDD group. Additionally, any anxiety disorder was observed more frequently in the BDD/OCD patients than in the BDD patients.

Although obsessional, schizoid, and narcissistic characteristics have been observed in BDD patients,28,29 Phillips et al17 systematically studied personality disorders in BDD. A higher proportion of patients with BDD than those with OCD had paranoid personality disorder, whereas patients with comorbid BDD/OCD were more likely to have avoidant personality disorder than those with OCD and BDD.17 In the same study, patients in OCD and comorbid BDD/OCD groups were more likely to have obsessive-compulsive personality disorder than patients with BDD, at a trend level for both groups.17 In our study, avoidant and narcissistic personality disorders were more prevalent in the BDD group than in the OCD group. Also in our study, rates of histrionic personality disorder were higher in the BDD and BDD/OCD groups compared with the OCD group. These findings have suggested that there may have been a relationship between BDD avoidant personality disorders and cluster B personality disorders, especially narcissistic personality disorder. Apart from the findings of Phillips et al,17 we found that the frequency of obsessive-compulsive personality disorder was no different between the groups. Also, we found that any personality disorder was more common in the BDD group than in the OCD group.

Our findings on comorbidity rates suggest that whereas patients with only OCD or BDD/OCD were more likely to have any depressive disorder than those with BDD, patients with BDD had higher rates of personality disorders than OCD patients. Although OCD has been considered an anxiety disorder, our results on comorbidity with other anxiety disorders in OCD patients fail to provide enough difference between OCD and BDD.

Our study is limited by the low number of cases recruited, which may have affected the power of the study to find some of the hypothesized differences between the groups. Our study was carried out in similar patients in terms of age, sex ratios, and age at disease onset, but our study sample also was heterogeneous with respect to educational level and duration of illness. In order to uncover the relationships between OCD and BDD, studies need to be conducted with a larger group of patients.

  CONCLUSIONS

The findings of our study demonstrate that the comorbid BDD/OCD and OCD groups had significantly longer duration of illness and tended to have higher HRSA scores and more frequent depressive disorders compared with the BDD group.

Our results can be interpreted as showing that BDD patients exhibit more severe personality pathologies compared with OCD patients, whereas anxiety and depression might be more common with OCD than BDD. This finding would help clinicians develop better clinical care of BDD patients by suggesting a therapeutic approach that includes interventions aimed at personality disorders, especially narcissistic and avoidant personality disorders, alongside pharmacological treatment.

Studies about the relationships between OCD and BDD are needed to better understand similarities and differences of the disorders.

DISCLOSURES: The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

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CORRESPONDENCE: Ras?it Tükel, MD Istanbul University Istanbul Faculty of Medicine Department of Psychiatry Capa, Istanbul, Turkey E-MAIL: rtukel@gmail.com