Elsevier

Clinical Psychology Review

Volume 49, November 2016, Pages 55-66
Clinical Psychology Review

Review
Suicidality in body dysmorphic disorder (BDD): A systematic review with meta-analysis

https://doi.org/10.1016/j.cpr.2016.08.002Get rights and content

Highlights

  • The association between a diagnosis of BDD and suicidality was examined.

  • The meta-analysis confirmed that suicidality in BDD is an important concern.

  • BDD is more strongly linked to suicidality than other related illnesses including OCD and anorexia nervosa.

  • There is lack of evidence about the psychological mechanisms of suicidality in BDD.

Abstract

Although a considerable number of studies have indicated that the rates of suicidal thoughts and behaviors in Body Dysmorphic Disorder (BDD) are high, no systematic review has been undertaken to explore the strength and patterns of the relationship between suicidality and BDD. This is the first systematic review and meta-analysis which aimed to examine the association between BDD and suicidality and the mechanisms underlying suicidality in BDD. Searches of five bibliographic databases including Medline, PsychINFO, Embase, Web of Science and CINAHL, were conducted from inception to June 2015. Seventeen studies were included in the review. Meta-analyses were performed using random effect models to account for the high levels of heterogeneity in the data. A positive and statistically significant association was found between BDD and suicidality (OR = 3.63, 95% CI = 2.62 to 4.63). Subgroup analyses showed that BDD was associated with increased odds for both, suicide attempts (OR = 3.30, 95% CI = 2.18 to 4.43) and suicidal ideation (OR = 2.57, 95% CI = 1.44 to 3.69). The evidence concerning suicide deaths in BDD was scarce. BDD-specific factors and comorbid diagnoses of Axis I disorders were likely to worsen suicidality in BDD. However, the modest number, and the low methodological quality, of the studies included in this review suggest caution the interpretation of these findings.

Introduction

Body dysmorphic disorder (BDD) is a serious, incapacitating mental health condition characterized by a series of symptoms related to body image concerns, such as recurrent intrusive thoughts about perceived deformations or flaws in physical appearance (American Psychiatric Association, 2013). The prevalence of BDD is estimated to be about 2% in the general population (Buhlmann et al., 2010, Koran et al., 2008), whereas in people seeking cosmetic surgery a BDD rate of 15.6% have been reported (Buhlmann et al., 2010). Although more common than other severe mental health conditions, such as schizophrenia and anorexia nervosa that range in prevalence from 0.5 to 1% in the general population (Hoek and Hoeken, 2003, Saha et al., 2005), BDD remains often unrecognized in clinical practice and its association with other serious mental health adversities, including suicidal ideation and suicide attempts has received scant research attention (Veale & Bewley, 2015). In this study the term suicidality was used to refer to suicidal ideation, plans and attempts and suicide deaths. It should be noted that in psychiatric inpatient settings, BDD is rarely identified unless a structured diagnostic interview is used (Grant et al., 2001, Conroy et al., 2008, Veale et al., 2015). This has the consequence of under-estimating the number of patients with BDD, who are usually misdiagnosed as having depression, as well as the rates of suicide risk in people with BDD.

BDD is classified under the category of obsessive-compulsive and related disorders in DSM-5, whereas in previous versions of DSM it was included in the category of somatoform disorders (American Psychiatric Association, 2000, American Psychiatric Association, 2013). This shift in the conceptualization of BDD is consistent with the scientific literature showing that BDD and Obsessive Compulsive Disorder (OCD) are distinct, but closely related, and often comorbid, mental illnesses (Frare et al., 2004, Phillips, 2007). A recent systematic review and meta-analysis confirmed that there is a strong relationship between OCD and suicidality (Angelakis, Gooding, Tarrier, & Panagioti, 2015). Considering, therefore, the commonalities between BBD and OCD, which are accompanied by similar levels of functional impairment, we anticipated that suicidality also is manifest in people experiencing BDD. Consistent with this view, a number of studies have shown that patients with BDD are at particularly high risk of experiencing suicidality (e.g., Phillips, 2007, Phillips et al., 2005). For example, prevalence estimates of suicide attempts in people with BDD has been reported as 7.2% (Rief, Buhlmann, Wilhelm, Borkenhagen, & Brähler, 2006). The prevalence of such attempts in the general population has been documented as 2.7% world-wide (Nock et al., 2008), and in those with anxiety disorders and schizophrenia spectrum disorders as 3.4% and 10.9% respectively (Barak et al., 2008, Nepon et al., 2010).

Despite people with BDD being at high risk of engaging in suicide attempts, understanding the links between the severity and type of BDD symptoms and the development and maintenance of suicidality is under-researched in the extant literature. BDD is accompanied by high levels of psychological distress, hopelessness, and feelings of embarrassment, shame, or discomfort related to appearance and body image (Phillips, 2000, Phillips et al., 1993, Veale et al., 1996, Veale, Gournay, et al., 1996). As a consequence, people with BDD often feel socially anxious, and withdraw from, or avoid, social interactions (Hollander and Aronowitw, 1999, Veale and Roberts, 2014). Empirically based contemporary models of suicidality indicate that such negative feelings, experiences, and perceptions, especially when linked with social isolation, are risk factors for the triggering, and maintenance, of suicidal thoughts, behaviors, and acts (Johnson et al., 2008, O'Connor and Nock, 2014, Tarrier et al., 2013, Williams, 1997). Comorbid depressive symptoms also are common features of BDD (Phillips, Didie, & Menard, 2007) and may amplify relationships between the range of negative perceptions associated with having BDD, resultant social isolation, and suicidality. To date, only one study (Witte, Didie, Menard, & Phillips 2012) attempted to investigate pathways to suicidality in people with BDD following a theoretical framework as postulated by the interpersonal-psychological theory of suicide (Joiner, 2005, Van Orden et al., 2010). Among the key variables that predicted suicide attempts in BDD patients as supported by the study's data were a diagnosis of PTSD, lifetime work impairment owning to BDD and lifetime BDD-related restrictive food intake. Major depressive disorder together with lifetime work impairment were found to be among the critical variables that predicted suicidal ideation in BDD.

In the absence of a systematic review, however, it is difficult to ascertain the levels of, and the mechanisms underlying suicidality in those experiencing BDD. Therefore, we decided to undertake a systematic review and meta-analysis with the following three core objectives:

  • i

    To systematically synthesize and quantify any association between BBD and suicidality.

  • ii

    To examine the underlying mechanisms of suicidality in BDD, which are likely to include specific features of BDD (e.g., severity, specific symptoms or sub-types), psychiatric comorbidities (e.g., depression, OCD) and other clinical, psychological or demographic factors.

  • iii

    To examine whether the co-presentation of OCD and BDD further escalates the risk for suicidality over and above the effects of OCD and BDD alone.

Section snippets

Methods

This systematic review and meta-analysis was performed and presented in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement (Moher, Liberati, Tetzlaff, & Altman, 2009).

Results

The search strategy yielded 325 articles. Of these, 51 were relevant for full-text screening. As shown in the flowchart (Fig. 1), 37 studies were eligible to be included in the review, but 18 were based on the same sample of participants (see Appendix 1). Among these 18 studies, only one study (which provided the most complete data) was entered in the meta-analysis. Therefore, this review comprised 20 independent studies.

Summary of main findings

The first aim of this systematic review and meta-analysis was to investigate the associations between BDD and suicidal thoughts, attempts and deaths. Our findings confirmed that suicidality in BDD is a substantial concern that has not received sufficient research attention. Individuals diagnosed with BDD were four times more likely to experience suicidal ideation and 2.6 times more likely to engage in suicide attempts compared to individuals without BDD. These estimates are at least as high as

References (70)

  • D. Moher et al.

    Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement

    Volucella

    (2009)
  • G. Perugi et al.

    Prevalence, phenomelogy and comorbidity of body dysmorphic disorder (dysmorphophobia) in a clinical population

    International Journal of Psychiatry in Clinical Practice

    (1997)
  • K.A. Phillips et al.

    A comparison study of body dysmorphic disorder and obsessive-compulsive disorder

    Journal of Clinical Psychiatry

    (1998)
  • T.P. Sokero et al.

    Prospective study of risk factors for attempted suicide among patients with DSM-IV major depressive disorder

    British Journal of Psychiatry

    (2005)
  • D. Veale et al.

    Body dysmorphic disorder

    British Journal of Psychiatry

    (1996)
  • H. Weingarden et al.

    Anxiety and shame as risk factors for depression, suicidality, and functional impairment in body dysmorphic disorder and obsessive compulsive disorder

    (2016)
  • J.M.G. Williams

    Cry of pain

    (1997)
  • C. Altamura et al.

    Clinical and subclinical body dysmorphic disorder

    European Archives of Psychiatry and Clinical Neuroscience

    (2001)
  • American Psychiatric Association

    Diagnostic and statistical manual of mental disorders, fourth edition, text revision (DSM-IV-TR)

    (2000)
  • American Psychiatric Association

    Diagnostic and statistical manual of mental disorders, fifth edition (DSM-V)

    (2013)
  • G. Arsenault-Lapierre et al.

    Psychiatric diagnoses in 3275 suicides: A meta-analysis

    BMC Dermatol.

    (2004)
  • M. Borenstein et al.

    Comprehensive meta-analysis

    (2005)
  • Centers for Disease Control and Prevention

    Web-based injury statistics query and reporting system (WISQARS): Data & statistics

  • D.L. Conceicao Costa et al.

    Body dysmorphic disorder in patients with obsessive-compulsive disorder: Prevalence and clinical correlates

    Depression and Anxiety

    (2012)
  • M.J. de Brito et al.

    Body dysmorphic disorder in patients seeking abdominoplasty, rhinoplasty, & rhytidectomy

    Plastic & Reconstructive Surgery

    (2015)
  • J. Dyl et al.

    Body dysmorphic disorder and other clinically significant body image concerns in adolescent psychiatric inpatients: Prevalence and clinical characteristics

    Child Psychiatry and Human Development

    (2006)
  • M. Egger et al.

    Bias in meta-analysis detected by a simple, graphical test

    British Medical Journal

    (1997)
  • M.B. First et al.

    Structured clinical interview for DSM-IV-TR axis I disorders, research version, patient edition. (SCID-I/P)

    (2002)
  • J.E. Grant et al.

    Prevalence and clinical features of body dysmorphic disorder in adolescent and adult psychiatric inpatient

    Journal of Clinical Psychology

    (2001)
  • J.E. Grant et al.

    Body dysmorphic disorder in patients with anorexia nervosa: Prevalence, clinical features, and delusionality of body image

    International Journal of Eating of Disorders

    (2002)
  • E.C. Harris et al.

    Suicide as an outcome for mental disorders: A meta-analysis

    British Journal of Psychiatry

    (1997)
  • J.P.T. Higgins et al.

    Measuring inconsistency in meta-analyses

    British Medical Journal

    (2003)
  • H.W. Hoek et al.

    Review of the prevalence and incidence of eating disorders

    International Journal of Eating Disorders

    (2003)
  • E. Hollander et al.

    Comorbid social anxiety and body dysmorphic disorder: Managing the complicated patient

    Journal of Clinical Psychiatry

    (1999)
    J.E. Kittler et al.

    Weight concerns in individuals with body dysmorphic disorder

    Eating Behaviors

    (2007)
  • J. Johnson et al.

    Suicide risk in schizophrenia: explanatory models and clinical implications: The schematic appraisal model of suicide (SAMS)

    Psychology & Psychotherapy

    (2008)
  • Cited by (0)

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