Cross-sectional/retrospective studies indicate that individuals with body dysmorphic disorder (BDD) have markedly impaired psychosocial functioning. However, no study has prospectively examined functioning in BDD. In this study, which is to our knowledge the first prospective study of the course of BDD, psychosocial functioning was assessed at baseline and over 1–3 years (mean = 2.7 ± 0.9 years) of follow-up with the Global Assessment of Functioning scale (GAF), Social and Occupational Functioning Scale (SOFAS), and LIFE-RIFT (Range of Impaired Functioning Tool). Psychosocial functioning was poor during the follow-up period. Functioning remained stably poor over time on the SOFAS and LIFE-RIFT, although there was a trend for a gradual and slight improvement on the GAF over time. The cumulative probability of attaining functional remission on the GAF (score > 70 for at least 2 consecutive months) during the follow-up period was only 5.7%. On the SOFAS, the cumulative probability of attaining functional remission (score > 70 for at least 2 consecutive months) was 10.6%. BDD severity significantly predicted functioning on the GAF (p = 0.0012), SOFAS (p = 0.0017), and LIFE-RIFT (p = 0.0015). A trend for a time-by-BDD severity interaction was found on the GAF (p = 0.033) but not the SOFAS or LIFE-RIFT. More delusional BDD symptoms also predicted poorer functioning on all measures, although this finding was no longer significant when controlling for BDD severity. Functioning was not predicted, however, by age, gender, BDD duration, or a personality disorder. In conclusion, psychosocial functioning was poor over time, and few subjects attained functional remission. Greater BDD severity predicted poorer functioning.
Body dysmorphic disorder, a distressing or impairing preoccupation with an imagined or slight defect in one’s physical appearance (e.g., “scarred” skin or a “deformed” nose), is a relatively common disorder (Bienvenu et al., 2000 and Rief et al., 2006). Descriptions of BDD during the past century have emphasized these individuals’ poor psychosocial functioning (Morselli, 1891 and Phillips, 1991). However, functioning in BDD has received only limited investigation.
In an early study, 97% of 30 subjects with BDD reported a history of avoiding usual social or occupational activities because of embarrassment over their perceived appearance defects (Phillips et al., 1993). Subsequent studies which used standard functioning measures reported impairment in psychosocial functioning. In a BDD pharmacotherapy study (n = 20), Schneier Disability Profile scores reflected moderate functional impairment ( Hollander et al., 1999). In a study of 62 patients with BDD (85% of whom participated in a placebo-controlled pharmacotherapy study, Phillips et al., 2002), scores on the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36) ( Ware, 1993) were markedly poor in all mental health domains. For example, on the SF-36 subscale that assesses role limitations due to emotional problems, BDD subjects’ scores were 1.6 standard deviation units poorer than US population norms; on the social functioning subscale, their scores were 2.2 standard deviation units poorer ( Phillips, 2000). Similarly poor SF-36 scores were reported in two small open-label pharmacotherapy studies ( Phillips, 2006 and Phillips and Najjar, 2003). Mental health-related SF-36 subscale scores in all three studies were poorer than norms for clinical depression ( Ware, 1993). These studies also found impaired functioning on the Global Assessment of Functioning scale (GAF), Social and Occupational Functioning Scale (SOFAS), and Longitudinal Interval Follow-Up Evaluation (LIFE) ( American Psychiatric Association, 1994 and Keller et al., 1987). However, these studies are limited by relatively small sample sizes. In addition, studies which used standard functioning measures consisted entirely or largely of pharmacotherapy trial participants, which may have introduced bias.
The present study examined the following aspects of psychosocial functioning in BDD over 1–3 years (mean = 2.7 ± 0.9 years) of follow-up: level of psychosocial functioning, stability of functional impairment, the probability of attaining “functional remission”, and predictors of psychosocial functioning. To our knowledge, this is the first report of prospectively assessed psychosocial functioning in BDD. (We have previously reported on this sample’s cross-sectional/retrospectively assessed functioning from the intake interview, Phillips et al., 2005a.) The present study had a larger sample and broader inclusion criteria than previous studies, which may increase the generalizability of the findings. We hypothesized that (1) psychosocial functioning would be poor and remain poor over time; (2) few subjects would “functionally remit” over time; and (3) more severe BDD symptoms would predict poorer functioning over time. We were also interested in whether delusionality of BDD appearance beliefs would predict poorer functioning. In a previous cross-sectional study, delusional BDD beliefs were associated with poorer functioning/quality of life on two of three SF-36 mental health subscales (Phillips, 2000). A report from the present sample found that at the time of intake into the study, greater delusionality was significantly, although modestly, associated with poorer scores on three of seven functioning/quality of life scales/subscales (Phillips et al., 2005a). This question is of clinical interest, as it is useful for clinicians to know whether more delusional patients function more poorly over time. This question also has some relevance for DSM-V. In DSM-IV, non-delusional BDD and delusional BDD are classified separately (BDD as a somatoform disorder and delusional BDD as a psychotic disorder). However, the nature of the relationship between these BDD variants is unclear (Phillips, 2004), and data are needed on delusionality in BDD. In addition, delusionality/insight may be conceptualized as a dimension that characterizes a number of disorders (Eisen et al., 2004 and Phillips, 2004), yet little is known about the relationship between delusionality and functional impairment.
