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