Body image is an important aspect of body dysmorphic disorder (BDD) which has received little investigation. Ninety-two BDD participants who participated in one of three BDD pharmacotherapy studies completed the Multidimensional Body-Self Relations Questionnaire, which assesses attitudinal body image, specifically evaluations of and investment in appearance, health/illness, and physical fitness. Scores were compared to population norms. Compared to norms, BDD participants were significantly less satisfied with their appearance. Less satisfaction was associated with more severe BDD and greater delusionality. Men with BDD were significantly more invested in their appearance compared to male population norms. Compared to population norms, males and females with BDD felt less physically healthy and females were less invested in a healthy lifestyle. However, compared with population females, females with BDD were less alert to being ill. These findings suggest that patients with BDD differ from population norms in a number of important aspects of body image.
Body dysmorphic disorder (BDD) is characterized by a distressing or impairing preoccupation with an imagined or slight defect in appearance that causes clinically significant distress or functional impairment. BDD appears relatively common and is associated with high rates of morbidity (Phillips, 2005). Although body image dissatisfaction is considered by some to be a core feature of BDD (Cororve and Gleaves, 2001 and Rosen and Rameriz, 1998), this topic has received little investigation.
Body image is conceived as one's attitudinal dispositions toward the physical self (Cash & Pruzinsky, 2002). Body image is multidimensional and encompasses perceptions, thoughts, feelings, and behaviors not only about physical appearance but also one's body's competence, or “fitness,” and its biological integrity, or “health/illness” (Cash, 2000). This topic has received much attention among students (Miller et al., 2000) and cosmetic surgery patients (Sarwer et al., 2003). However, this important construct has received only scant empirical attention in individuals with BDD.
One study that compared 51 individuals with BDD to 45 individuals with an eating disorder found comparable levels of body image dissatisfaction on the Body Dysmorphic Disorder Examination (BDDE) (Rosen & Rameriz, 1998). A more recent study (Hrabosky et al., 2009) that compared multiple facets of body image among BDD patients and eating disorder patients found that the BDD group reported greater overall body dissatisfaction than clinical controls and was comparable to the eating disorder groups. In addition, participants with BDD reported greater self-evaluative investment in and more appearance-managing investment than those with anorexia nervosa. Participants with BDD also reported greater overall body image disturbance and a more negative impact of body image on quality of life than participants with anorexia or bulimia nervosa.
Choi, Pope, and Olivardia (2002) examined attitudinal aspects of body image using the Multidimensional Body-Self Relations Questionnaire (MBSRQ; Brown et al., 1990 and Cash, 2000) in 24 male weightlifters with muscle dysmorphia, a form of BDD that consists of preoccupation with leanness and muscularity. Participants with muscle dysmorphia reported poorer body image and greater appearance dissatisfaction than males without muscle dysmorphia. One BDD study (n = 200) examined gender similarities and differences in body image, finding that women had greater body image disturbance than men on the BDDE ( Phillips, Menard, & Fay, 2006).
Important yet overlooked dimensions of body image are the body's competence, or “fitness,” and its biological integrity, or “health/illness” (Brown et al., 1990 and Cash, 2000). While data are limited, BDD patients appear to have poorer perception of their physical well-being compared to community norms. Sixty-two individuals who were seeking consultation or treatment in a BDD specialty research and clinical program (Phillips, 2000) had lower scores than U.S. population norms on the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36; Ware, 1993) subscales that assessed physical health status and physical-health related quality of life. However, those with BDD had somewhat better scores than outpatients with type II diabetes, a recent myocardial infarction, or clinical depression (Phillips, 2000). Comparable results were found among 176 individuals with BDD, one-third of whom were not receiving mental health treatment and two-thirds of whom were receiving treatment (primarily in the community) (Phillips, Menard, Fay, & Pagano, 2005). To our knowledge, no prior study has examined self-evaluations of fitness among individuals with BDD.
This report used a reliable and valid measure of body image (MBSRQ) to assess attitudinal aspects of body image—specifically, evaluations of and investment in physical appearance, health/illness, and fitness in male and female BDD patients compared to a normative sample. To our knowledge, this is the first study to examine body image using a broad definition that includes evaluations of appearance, health/illness, and fitness in BDD. We hypothesized that, compared to population norms, BDD patients would be less satisfied with and more invested in their appearance. We also hypothesized that patients with more severe BDD and less insight (i.e., greater delusionality) regarding their appearance would be less satisfied with how they look. We additionally hypothesized that BDD patients would report poorer evaluations of their physical health than those reported in population norms. We were particularly interested in BDD patients’ evaluations of their health/illness, given that BDD is classified as a somatoform disorder in DSM-IV, and little is known about this important aspect of BDD.
