یک مطالعه مقایسه اختلال بدریخت انگاری در مقابل هراس اجتماعی

Body dysmorphic disorder (BDD) shares many characteristics with social phobia (SP), including high levels of social anxiety and avoidance, but to our knowledge no studies have directly compared these disorders’ demographic and clinical features. Demographic and clinical features were compared in individuals with BDD (n=172), SP (n=644), and comorbid BDD/SP (n=125). SP participants had a significantly earlier age of onset and lower educational attainment than BDD participants. BDD participants were significantly less likely to ever be married than SP participants, had a greater likelihood of ever being psychiatrically hospitalized, and had significantly lower mean GAF scores than SP participants. The two groups had different comorbidity patterns, which included a greater likelihood for BDD participants to have comorbid obsessive-compulsive disorder (OCD) or an eating disorder, vs. a greater likelihood for SP participants to have a comorbid non-OCD anxiety disorder. The comorbid BDD/SP group had significantly greater morbidity across several domains than the SP only group, but not the BDD only group. In summary, although BDD and SP were similar across many demographic and clinical features, they had important differences. Future studies are needed to confirm these findings and address similarities and differences between these disorders across a broader range of variables.

Body dysmorphic disorder (BDD) is an often severe mental disorder that consists of distressing or impairing preoccupations with nonexistent or slight defects in appearance. BDD appears to be closely related to several anxiety disorders, particularly obsessive-compulsive disorder (OCD) and social phobia (SP) (Phillips et al., 1998, Frare et al., 2004, Phillips et al., 2007 and Fang and Hofmann, 2010). Much attention has been paid to similarities between BDD and OCD (Phillips et al., 1998, Frare et al., 2004, Phillips and Stout, 2006, Phillips and Kaye, 2007, Phillips et al., 2007 and Stewart et al., 2008). Indeed, BDD is often conceptualized as an obsessive-compulsive (OC)-spectrum disorder— i.e., a disorder that shares features with OCD and may be closely related to OCD (Cohen and Hollander, 1997, Goldsmith et al., 1998, Mataix-Cols et al., 2007 and Phillips et al., 2010). However, BDD also shares many characteristics with SP (Veale et al., 2003, Pinto and Phillips, 2005, Coles et al., 2006 and Kelly et al., 2010), including high levels of social anxiety and social avoidance (Veale et al., 2003, Pinto and Phillips, 2005, Fang and Hofmann, 2010 and Kelly et al., 2010). However, to date, no studies to our knowledge have ever directly compared the demographic and clinical features of BDD to SP. BDD and SP are both characterized by fear of negative evaluation in social situations (Pinto and Phillips, 2005 and Bögels et al., 2010) and avoidance of social interactions (Veale et al., 2003, Stangier et al., 2006 and Kelly et al., 2010), although in BDD, social fear and avoidance are largely related to anxiety that the bodily “defects” will be perceived by others and considered unacceptable (Kelly et al., 2010). Indeed, although BDD and SP have not been directly compared, levels of social anxiety in BDD are similar to those reported for SP, with social anxiety symptoms in BDD ranging from 1.3 to 1.7 S.D. units higher than normative samples on the Social Avoidance and Distress Scale (SADS), the Social Phobia Inventory (SPIN) and Social Phobia scales (Veale et al., 2003, Pinto and Phillips, 2005 and Kelly et al., 2010). Social avoidance is particularly marked in BDD and in SP (Schneier et al., 2002, Pinto and Phillips, 2005, Stangier et al., 2006 and Kelly et al., 2010), contributing to poor social and occupational functioning in both disorders (Schneier et al., 1994, Wittchen et al., 2000, Kessler, 2003 and Kelly et al., 2010). BDD and SP appear to have other features in common. For instance, individuals with BDD and those with SP are more likely than healthy controls to interpret ambiguous social information (e.g., neutral facial expressions or ambiguous social scenarios) as hostile and threatening (Amir et al., 1998, Stopa and Clark, 2000, Buhlmann et al., 2002 and Buhlmann et al., 2006). Both disorders are characterized by a tendency for negative self-focused thoughts (Hofmann and Barlow, 2002, Veale, 2004, Phillips, 2005 and Neziroglu et al., 2008) (although these characteristics are shared by other disorders as well). In addition, there is a high lifetime prevalence of comorbid SP in individuals with BDD, with rates ranging from 12–69 % (Hollander et al., 1993, Veale et al., 1996, Phillips and Diaz, 1997, Zimmerman and Mattia, 1998, Gunstad and Phillips, 2003 and Phillips et al., 2005a); in the largest studies that examined comorbidity with a standard assessment measure, 37% of 293 participants and 39% of 200 participants with BDD had comorbid lifetime SP (Gunstad and Phillips, 2003 and Phillips et al., 2005a). The prevalence of comorbid BDD in individuals with SP appears lower (5–12%), but to our knowledge has been examined in only two small studies (Brawman-Mintzer et al., 1995 and Wilhelm et al., 1997). Furthermore, in some Eastern cultures (e.g., Japan), BDD is considered a type of SP known as Taijin-kyofu-sho (TKS) (Kleinknecht et al., 1997, Maeda and Nathan, 1999 and Choy et al., 2008). Taken together, these findings suggest that BDD and SP may be related disorders. However, BDD and SP appear to have important differences. For instance, BDD, but not SP, is characterized by prominent time-consuming repetitive behaviors (e.g., mirror checking, skin picking, excessive grooming) that are aimed at checking, fixing, hiding, or obtaining reassurance about the perceived appearance flaws. Regarding social anxiety specifically, clinical observations indicate that BDD-related social anxiety focuses specifically on concerns that others will judge the person’s physical appearance (e.g., skin, hair, nose) negatively (Phillips, 2009). In a recent study, only 14% of individuals with BDD without comorbid SP had clinically significant social anxiety not related to appearance concerns, whereas 62% had clinically significant social anxiety due to appearance concerns or other sources (for most participants, BDD was the primary diagnosis) ( Kelly et al., 2010). Furthermore, in the only prospective observational study of the course of BDD, examination of time-varying associations between BDD and comorbid SP indicated that change in symptoms of BDD and SP were not closely linked in time (however, statistical power was somewhat limited) ( Phillips and Stout, 2006). For participants whose SP symptoms remitted, about half still met full DSM-IV criteria for BDD. Overall, these findings suggest that BDD and SP are similar across a number of clinical features and are highly comorbid, but they have some differences and do not appear to be the same disorder. Currently, the relationship of BDD to disorders with similar features is an important topic of discussion (Mataix-Cols et al., 2007, Fang and Hofmann, 2010 and Phillips et al., 2010). A direct comparison of the demographic and clinical features of BDD vs. SP would provide useful information that could shed light on the relationship between them. In turn, this could be useful for classification and assessment. This report presents comparisons of demographic and clinical characteristics of BDD vs. SP vs. comorbid BDD and SP. Because to our knowledge there have been no previous comparisons of BDD and SP, and because both disorders are associated with significant morbidity and impairment in psychosocial functioning (Phillips et al., 2005b and Keller, 2006), no specific hypotheses were established for comparisons of morbidity in BDD vs. SP. However, we predicted that the comorbid BDD/SP group would have greater morbidity than the BDD only and SP only groups, given that individuals with more comorbidity, including BDD and anxiety disorders, generally have greater functional impairment (Phillips et al., 1998, Belzer and Schneier, 2004 and Frare et al., 2004) and suicidality (Phillips et al., 1998, Frare et al., 2004, Sareen et al., 2005 and Pfeiffer et al., 2009). Because BDD has been hypothesized to be an OC-spectrum disorder and has similarities with both OCD and eating disorders (Grant and Phillips, 2004, Hrabosky et al., 2009 and Phillips et al., 2010), we hypothesized that BDD would be more highly comorbid than SP with proposed OC-spectrum disorders (OCD, hypochondriasis, trichotillomania) and eating disorders (which have also been proposed by some to be OC-spectrum disorders) (Hollander et al., 2007). In addition, as SP has high comorbidity with other anxiety disorders and has many similarities with them, we predicted that a significantly higher proportion of individuals with SP would have comorbid anxiety disorder diagnoses (other than OCD) than individuals with BDD (Pollack, 2001 and Keller, 2006).