Age at onset and clinical correlates in body dysmorphic disorder

Abstract

Objective

Age at onset is an important clinical feature of all disorders. However, no prior studies have focused on this important construct in body dysmorphic disorder (BDD). In addition, across a number of psychiatric disorders, early age at disorder onset is associated with greater illness severity and greater comorbidity with other disorders. However, clinical correlates of age at onset have not been previously studied in BDD.

Methods

Age at onset and other variables of interest were assessed in two samples of adults with DSM-IV BDD; sample 1 consisted of 184 adult participants in a study of the course of BDD, and sample 2 consisted of 244 adults seeking consultation or treatment for BDD. Reliable and valid measures were used. Subjects with early-onset BDD (age 17 or younger) were compared to those with late-onset BDD.

Results

BDD had a mean age at onset of 16.7 (SD = 7.3) in sample 1 and 16.7 (SD = 7.2) in sample 2. 66.3% of subjects in sample 1 and 67.2% in sample 2 had BDD onset before age 18. A higher proportion of females had early-onset BDD in sample 1 but not in sample 2. On one of three measures in sample 1, those with early-onset BDD currently had more severe BDD symptoms. Individuals with early-onset BDD were more likely to have attempted suicide in both samples and to have attempted suicide due to BDD in sample 2. Early age at BDD onset was associated with a history of physical violence due to BDD and psychiatric hospitalization in sample 2. Those with early-onset BDD were more likely to report a gradual onset of BDD than those with late-onset in both samples. Participants with early-onset BDD had a greater number of lifetime comorbid disorders on both Axis I and Axis II in sample 1 but not in sample 2. More specifically, those with early-onset BDD were more likely to have a lifetime eating disorder (anorexia nervosa or bulimia nervosa) in both samples, a lifetime substance use disorder (both alcohol and non-alcohol) and borderline personality disorder in sample 1, and a lifetime anxiety disorder and social phobia in sample 2.

Conclusions

BDD usually began during childhood or adolescence. Early onset was associated with gradual onset, a lifetime history of attempted suicide, and greater comorbidity in both samples. Other clinical features reflecting greater morbidity were also more common in the early-onset group, although these findings were not consistent across the two samples.

Introduction

Body dysmorphic disorder (BDD) is a common and often severe disorder characterized by a distressing or impairing preoccupation with an imagined or slight defect in appearance [1]. In recent years, there have been increased efforts to characterize the phenomenology and course of BDD, and associated morbidity, such as suicidality and psychosocial functioning [2], [3], [4], [5], [6], [7]. However, to our knowledge, detailed information about age at onset and clinical correlates of age at onset has not yet been examined in BDD.

Age at onset is an important clinical feature of all disorders. In addition, age at onset has important correlates in many different disorders such as major depressive disorder [8], [9], [10], bipolar disorder [11], [12], schizophrenia [13], [14], [15], panic disorder [16], [17], [18], [19], social phobia [20], [21] and obsessive-compulsive disorder (OCD; [22], [23], [24], [25], [26], [27], [28], [29], [30], [31]). In general, early age at onset has been associated with greater severity of illness (eg, [8], [32]), although there are exceptions, particularly for panic disorder, for which some studies have found no differences in symptom severity between early-onset and late-onset patients [16], [19]. Furthermore, in many studies early age at onset is associated with increased comorbidity on both Axis I (eg, [8], [17]) and Axis II (eg, [9], [10], [18]), although not all studies have found this (eg, [19]). Such findings have clinical implications, in that age at onset could be indicative of a disorder’s severity and comorbidity, and could potentially lead to different therapeutic interventions.

Findings associated with age at onset in social phobia and OCD may be particularly relevant to the present study because these disorders may be closely related to BDD (see eg [33], [34]). However, findings in these disorders are inconclusive. Early age at onset was associated with greater symptom severity and increased comorbidity in one study on social phobia [20] but with greater comorbidity but not symptom severity in another study [21]. In OCD, early age at onset is usually associated with greater severity of symptoms [22], [24], [26], [28], [31], [35], [36] and greater comorbidity on both Axis I and Axis II [25], [27], [29], [30], [33]. However, Millet et al. [24], Grant et al. [22], and Tükel et al. [31] found comorbidity rates to be similar across groups with different ages of onset. Despite certain discrepancies in the literature, it appears that early age at onset is usually associated with greater symptom severity and increased comorbidity with other disorders. Therefore, we expected to find the same pattern with regard to age at onset in BDD.

Interestingly, studies on age at onset and clinical correlates in other disorders have usually not included measures of psychosocial functioning and quality of life, although there are some exceptions. Grant et al. [22], Rodriguez-Salgado et al. [37], and Pinto et al. [23] found no differences in quality of life or social or work impairment between patients with early-onset versus late-onset OCD. However, Biffin et al. [38] found that early age at onset in bipolar I disorder was associated with more impaired psychosocial functioning and poorer quality of life. Zisook et al. [8] found that early-onset major depressive disorder was associated with more impairment in occupational and social functioning and poorer quality of life, and Bellino et al. [15] found similar results for schizophrenia.

In this report, we examine age at BDD onset in more detail than in previous reports on BDD (we have previously reported only mean, standard deviation, and range of age at onset) [3], [39]. There is considerable discrepancy in how early age at onset is defined across studies of other disorders (eg, [22], [26]). In this study, we chose a cut-point of 17 and younger for early-onset, and 18 and older for late (or adult) onset, as this is the most common practice in the age at onset literature on other disorders (eg [9], [11], [17]), especially for OCD (eg, [23], [35]); thus, this cut-point provides the best comparative data and continuity with this literature. In addition, although such cut-offs are to some extent arbitrary, there is nevertheless a meaningful distinction to be made between adult and child/adolescent samples (eg, [9]).

We also examine clinical correlates of age at onset in BDD, which to our knowledge have not previously been examined. Based on the literature in other disorders, we hypothesized that early age at onset would be associated with greater severity of BDD and higher rates of comorbidity on Axis I and Axis II. In addition, although evidence from other disorders is mixed, based on our clinical impressions we hypothesized that early age at onset would be associated with poorer functioning and quality of life.

Much has been written about the need for replication in science (see eg, [40]). We address this concern by testing our hypotheses in two separate samples of individuals with BDD. These samples were recruited in different ways, and there were some differences in the measures that were used to assess the two samples (as described below).