Age at Onset and Clinical Correlates in Body Dysmorphic Disorder

Abstract

Objective:
Age at onset is an important clinical feature of all disorders. However, no prior studies have focused on this important construct in body dysmorphic disorder (BDD). In addition, across a number of psychiatric disorders, early age at disorder onset is associated with greater illness severity and greater comorbidity with other disorders. However, clinical correlates of age at onset have not been previously studied in BDD.

Methods:
Age at onset and other variables of interest were assessed in two samples of adults with DSM-IV BDD; sample 1 consisted of 184 adult participants in a study of the course of BDD, and sample 2 consisted of 244 adults seeking consultation or treatment for BDD. Reliable and valid measures were used. Subjects with early-onset BDD (age 17 or younger) were compared to those with late-onset BDD.

Results:
BDD had a mean age at onset of 16.7 (SD=7.3) in sample 1 and 16.7 (SD=7.2) in sample 2. 66.3% of subjects in sample 1 and 67.2% in sample 2 had BDD onset before age 18. A higher proportion of females had early-onset BDD in sample 1 but not in sample 2. On one of three measures in sample 1, those with early-onset BDD currently had more severe BDD symptoms. Individuals with early-onset BDD were more likely to have attempted suicide in both samples and to have attempted suicide due to BDD in sample 2. Early age at BDD onset was associated with a history of physical violence due to BDD and psychiatric hospitalization in sample 2. Those with early-onset BDD were more likely to report a gradual onset of BDD than those with late-onset in both samples. Participants with early-onset BDD had a greater number of lifetime comorbid disorders on both Axis I and Axis II in sample 1 but not in sample 2. More specifically, those with early-onset BDD were more likely to have a lifetime eating disorder (anorexia nervosa or bulimia nervosa) in both samples, a lifetime substance use disorder (both alcohol and non-alcohol) and borderline personality disorder in sample 1, and a lifetime anxiety disorder and social phobia in sample 2.

Conclusions:
BDD usually began during childhood or adolescence. Early onset was associated with gradual onset, a lifetime history of attempted suicide, and greater comorbidity in both samples. Other clinical features reflecting greater morbidity were also more common in the early-onset group, although these findings were not consistent across the two samples.

Full text

Age at Onset and Clinical Correlates in Body Dysmorphic
Disorder
Andri S. Bjornssona, Elizabeth R. Didieb,c, Jon E. Grantd, William Menardb, Emily Stalkere,
and Katharine A. Phillipsb,c
aDepartment of Psychology, University of Iceland bRhode Island Hospital cDepartment of
Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University dUniversity of
Minnesota School of Medicine eDickinson College
Abstract
OBJECTIVE—Age at onset is an important clinical feature of all disorders. However, no prior
studies have focused on this important construct in body dysmorphic disorder (BDD). In addition,
across a number of psychiatric disorders, early age at disorder onset is associated with greater
illness severity and greater comorbidity with other disorders. However, clinical correlates of age at
onset have not been previously studied in BDD.
METHODS—Age at onset and other variables of interest were assessed in two samples of adults
with DSM-IV BDD; sample 1 consisted of 184 adult participants in a study of the course of BDD,
and sample 2 consisted of 244 adults seeking consultation or treatment for BDD. Reliable and
valid measures were used. Subjects with early-onset BDD (age 17 or younger) were compared to
those with late-onset BDD.
RESULTS—BDD had a mean age at onset of 16.7 (SD=7.3) in sample 1 and 16.7 (SD=7.2) in
sample 2. 66.3% of subjects in sample 1 and 67.2% in sample 2 had BDD onset before age 18. A
higher proportion of females had early-onset BDD in sample 1 but not in sample 2. On one of
three measures in sample 1, those with early-onset BDD currently had more severe BDD
symptoms. Individuals with early-onset BDD were more likely to have attempted suicide in both
samples and to have attempted suicide due to BDD in sample 2. Early age at BDD onset was
associated with a history of physical violence due to BDD and psychiatric hospitalization in
sample 2. Those with early-onset BDD were more likely to report a gradual onset of BDD than
those with late-onset in both samples. Participants with early-onset BDD had a greater number of
lifetime comorbid disorders on both Axis I and Axis II in sample 1 but not in sample 2. More
specifically, those with early-onset BDD were more likely to have a lifetime eating disorder
(anorexia nervosa or bulimia nervosa) in both samples, a lifetime substance use disorder (both
alcohol and non-alcohol) and borderline personality disorder in sample 1, and a lifetime anxiety
disorder and social phobia in sample 2.
CONCLUSIONS—BDD usually began during childhood or adolescence. Early onset was
associated with gradual onset, a lifetime history of attempted suicide, and greater comorbidity in
© 2013 Elsevier Inc. All rights reserved.
Corresponding author. Tel.: 354-525-5177. Psychology Department, University of Iceland, Aragata 14, 101 Reykjavik, Iceland.
asb@hi.is.
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both samples. Other clinical features reflecting greater morbidity were also more common in the
early-onset group, although these findings were not consistent across the two samples.
Keywords
Body dysmorphic disorder; dysmorphophobia; age at onset; age of onset; comorbidity; symptom
severity; quality of life; suicidality
1. Introduction
Body dysmorphic disorder (BDD) is a common and often severe disorder characterized by a
distressing or impairing preoccupation with an imagined or slight defect in appearance [1].
In recent years, there have been increased efforts to characterize the phenomenology and
course of BDD, and associated morbidity, such as suicidality and psychosocial functioning
[2–7]. However, to our knowledge, detailed information about age at onset and clinical
correlates of age at onset has not yet been examined in BDD.
Age at onset is an important clinical feature of all disorders. In addition, age at onset has
important correlates in many different disorders such as major depressive disorder [8–10],
bipolar disorder [11–12], schizophrenia [13–15], panic disorder [16–19], social phobia
[20,21] and obsessive-compulsive disorder (OCD; [22–31]). In general, early age at onset
has been associated with greater severity of illness (eg, [8,32]), although there are
exceptions, particularly for panic disorder, for which some studies have found no differences
in symptom severity between early-onset and late-onset patients [16,19]. Furthermore, in
many studies early age at onset is associated with increased comorbidity on both Axis I (eg,
[8,17]) and Axis II (eg, [9,10,18]), although not all studies have found this (eg [19]). Such
findings have clinical implications, in that age at onset could be indicative of a disorder’s
severity and comorbidity, and could potentially lead to different therapeutic interventions.
Findings associated with age at onset in social phobia and OCD may be particularly relevant
to the present study because these disorders may be closely related to BDD (see eg [33,34]).
However, findings in these disorders are inconclusive. Early age at onset was associated
with greater symptom severity and increased comorbidity in one study on social phobia [20]
but with greater comorbidity but not symptom severity in another study [21]. In OCD, early
age at onset is usually associated with greater severity of symptoms [22,24,26,28,31,35,36]
and greater comorbidity on both Axis I and Axis II [25,27,29,30,33]. However, Millet et al.
[24], Grant et al. [22], and Tükel et al. [31] found comorbidity rates to be similar across
groups with different ages of onset. Despite certain discrepancies in the literature, it appears
that early age at onset is usually associated with greater symptom severity and increased
comorbidity with other disorders. Therefore, we expected to find the same pattern with
regard to age at onset in BDD.
Interestingly, studies on age at onset and clinical correlates in other disorders have usually
not included measures of psychosocial functioning and quality of life, a lthough there are
some exceptions. Grant et al. [22], Rodriguez-Salgado et al. [37], and Pinto et al. [23] found
no differences in quality of life or social or work impairment between patients with early-
onset versus late-onset OCD. However, Biffin et al. [38] found that early age at onset in
bipolar I disorder was associated with more impaired psychosocial functioning and poorer
quality of life. Zisook et al. [8] found that early-onset major depressive disorder was
associated with more impairment in occupational and social functioning and poorer quality
of life, and Bellino et al. [15] found similar results for schizophrenia.
In this report, we examine age at BDD onset in more detail than in previous reports on BDD
(we have previously reported only mean, standard deviation, and range of age at onset)
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[3,39]. There is considerable discrepancy in how early age at onset is defined across studies
of other disorders (eg, [22,26]). In this study, we chose a cut-point of 17 and younger for
early-onset, and 18 and older for late (or adult) onset, as this is the most common practice in
the age at onset literature on other disorders (eg [9,11,17]), especially for OCD (eg [23,35]);
thus, this cut-point provides the best comparative data and continuity with this literature. In
addition, although such cut-offs are to some extent arbitrary, there is nevertheless a
meaningful distinction to be made between adult and child/adolescent samples (eg [9]).
We also examine clinical correlates of age at onset in BDD, which to our knowledge have
not previously been examined. Based on the literature in other disorders, we hypothesized
that early age at onset would be associated with greater severity of BDD and higher rates of
comorbidity on Axis I and Axis II. In addition, although evidence from other disorders is
mixed, based on our clinical impressions we hypothesized that early age at onset would be
associated with poorer functioning and quality of life.
Much has been written about the need for replication in science (see eg [40]). We address
this concern by testing our hypotheses in two separate samples of individuals with BDD.
These samples were recruited in different ways, and there were some differences in the
measures that were used to assess the two samples (as described below).
2. Methods
2.1. Subjects
Sample 1—Subjects were 184 broadly ascertained adults with current or past DSM-IV
BDD who participated in an observational prospective interview study of the course of
BDD. Other papers have previously reported on various characteristics of this sample [e.g.,
3,41]. This report includes only data from the initial (intake) interview. Inclusion criteria
were DSM-IV BDD, including its delusional variant, and ability to be interviewed in person.
In this report, study participants younger than 18 were excluded from analyses. The only
exclusion criterion was the presence of an organic mental disorder. The study was approved
by the hospital institutional review board, and all subjects provided written informed consent
for their participation.
The study was conducted in a research and clinical BDD specialty program. Recruitment
sources consisted of mental health professionals (48.4%), advertisements (36.4%), brochures
and the program website (10.3%), friends and relatives of the subject (3.3%) and
nonpsychiatrist physicians (1.6%). All subjects received $50 as compensation for the intake
interview. In this sample, 88.6% (n = 163) met current criteria (during the past month) for
BDD; the rest of the sample had met full criteria for BDD at some point in their life (7.6%
were in partial remission, and 3.8% were in full remission at the time of the intake
interview). 75.5% of subjects considered BDD their most problematic lifetime disorder.
Sample 2—This sample was obtained from the same site as sample 1. Subjects were 244
adults with current DSM-IV BDD who were referred from a variety of sources for a clinical
evaluation or treatment of BDD. They participated in a phenomenology study of the clinical
features of BDD (n = 151) [e.g., 42,43] or in pharmacotherapy studies of BDD (n=93) [44–
48]. The treatment studies excluded individuals with a current substance use disorder, past
or current bipolar disorder, current clinically significant suicidality, or current inpatient or
residential treatment status. Other papers have previously reported on various characteristics
of this sample [e.g., 42,43]. This study was approved by the hospital institutional review
board, and all subjects provided written informed consent.
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2.2. Assessments
Measures of illness severity—Severity of BDD symptoms was assessed with three
measures: (1) The Yale-Brown Obsessive Compulsive Scale Modified for Body
Dysmorphic Disorder (BDD-YBOCS) [49] is a 12-item reliable and valid semi-structured
interview with scores ranging from 0 to 48. (2) The Psychiatric Status Rating Scale for Body
Dysmorphic Disorder (BDD-PSR) is based upon PSRs for other disorders, which are
included in the Longitudinal Interval Follow-Up Evaluation (LIFE) [50,51]. The BDD-PSR
is a reliable 7-item interviewer-rated measure of BDD severity that is based on DSM-IV
BDD criteria, with scores ranging from 1 to 7. (3) The Body Dysmorphic Disorder
Examination (BDDE) [52] is a 34-item semi-structured interview of BDD symptom severity
and negative body image, with scores ranging from 0 to 168. On all of these measures,
higher scores indicate greater illness severity.
Demographics and clinical features of BDD—The BDD Form (Phillips KA,
unpublished), which has been used in other BDD studies [e.g., 3,42,48], obtained data on
demographic characteristics and clinical features of BDD (eg, retrospectively assessed
course of illness, suicidality, violent behavior, and lifetime impairment in psychosocial
functioning). This measure was also used to determine age at BDD onset. Interviewers
carefully questioned participants about the age at which they first met full DSM-IV criteria
for BDD; each key DSM-IV criterion (appearance-related preoccupation, distress, and
impairment) was inquired about. To enhance the accuracy of age at onset information,
subjects were asked about events in their life around the time of reported BDD onset (eg,
grade in school, where they lived, memorable events). Participants were also asked about
age at onset of subclinical BDD symptoms–i.e., when they first started to dislike and
become concerned about their appearance.
The Brown Assessment of Beliefs Scale (BABS), a reliable and valid semistructured
interviewer-administered questionnaire, which consists of 7 items (scores range from 0–24),
was used to assess current delusionality of beliefs about appearance (eg, “I look ugly”, [53]).
The Hamilton Rating Scale for Depression is a 24-item reliable and valid interviewer-
administered measure of current depression symptoms (with scores ranging from 0 to 72)
[54]. On these measures, higher scores indicate greater symptom severity or more delusional
BDD beliefs.
Measures of co-morbidity—In sample 2, most subjects were assessed with the
Structured Clinical Interview for DSM-III-R (SCID-III) [55,56] and the Structured Clinical
Interview for DSM-III-R Personality Disorders (SCID-II) [57,58], although some subjects
were assessed with the DSM-IV versions of these interviews [59]. Because BDD was not
included in the DSM-III-R SCID, BDD was assessed with a reliable semi-structured
diagnostic instrument that is similar to the SCID and is based on DSM-IV criteria [60]. In
sample 1, the Structured Clinical Interview for DSM-IV, nonpatient version, (SCID-IV)
assessed Axis I co-morbidity [61], and the SCID for DSM-IV Axis II Personality Disorders
(SCID-II) assessed Axis II disorders [62].
Measures of psychosocial functioning—(1) Longitudinal Interval Follow-up
Evaluation Range of Impaired Functioning Tool (LIFE-RIFT) [63] is a reliable and valid
semi-structured measure of impairment in various domains (work, school, household duties,
recreation, relationships with friends and family, and satisfaction). Total scores range from
4–20. (2) The Social Adjustment Scale–Self-Report (SAS-SR) is a reliable and valid 54-item
self-report measure of current functioning in the following domains: work, social and
leisure, extended family, primary relationship, parental and family unit [64]. Scores range
from 0–4. (3) The Global Assessment of Functioning Scale (GAF) assessed global
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symptomatology and functioning [1]. (4) The Social and Occupational Functioning Scale
(SOFAS) assessed global functioning [1]. Both the GAF and the SOFAS range from 1 to
100. On the LIFE-RIFT and SAS-SR, higher scores reflect poorer functioning; on the GAF
and SOFAS, lower scores reflect poorer functioning.
Measures of quality of life—(1) The Medical Outcomes Study 36-Item Short-Form
Health Survey (SF-36) is a reliable and valid self-report questionnaire that measures mental
dimensions of health status and associated quality of life [65]. Each subscale has scores
ranging from 0 to 100, with lower scores reflecting poorer quality of life. (2) The Quality of
Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q) is a reliable and valid measure of
quality of life in eight domains: general activities, physical health, emotional well-being,
household, leisure, social, work, and school [66]. We used the “short form,” which yields a
total score for these different domains; lower scores reflect poorer quality of life.
As indicated in Table 1, some of the assessments differed across the two samples.
2.3. Statistical analysis
SPSS version 18 was used for analyses. Means, standard deviations, modes, medians, and
frequencies were calculated. Differences between early-onset (age 17 or younger) and late-
onset (age 18 or older) BDD were examined using chi-square analyses for categorical
variables and t tests for continuous variables. Given the exploratory nature of the analyses,
the alpha level was .05; we did not correct for multiple comparisons. Thus, due to the
number of comparisons, caution should be used in interpreting significant results, as some of
them may represent chance associations. All tests were two-tailed. For both studies, we
included only participants with current BDD when comparing current BDD and depression
symptom severity, BABS score, and current functioning and quality of life. In sample 1,
there was a statistically significant difference in gender for subjects with early-onset versus
late-onset BDD. As a result, we controlled for this variable in all analyses for sample 1 so
the gender difference would not bias the results, especially because we descriptively
compare results in the two samples, and there was not a gender difference in sample 2. Thus,
we report effect sizes as odds ratios for logistic regressions and adjusted R2 for linear
regressions. In sample 2 there were no differences in demographic variables. Therefore, we
report effect size estimates using Cohen’s
d
(
d
= .2 is a small effect size, .5 is medium, and .
8 is large) for continuous variables and the φ coefficient (Cramer’s V; V = .2 is a small
effect size, .5 is medium and .8 is large) for categorical variables.
Because of the exclusion criteria for the pharmacotherapy study participants in sample 2 (see
above), we included only the phenomenology subgroup (n=151) in analyses of bipolar
disorder, substance use disorder, and suicidality. More disorders were assessed in sample 1
than in sample 2 because different versions of the SCID were used for sample 1 versus most
of sample 2. There are occasional discrepancies between a group’s total number and the
sample size in analyses of a particular variable in both studies; this is due to missing data or
because some measures were added later to the studies. Finally, for some variables
(symptom severity, quality of life and functional impairment) data are available for only a
subset of the subjects included in sample 2; these were either reported or not depending on
the number of subjects for whom data were available (see Table 1).
3. Results
In sample 1, the mean age at BDD onset was 16.7 7.3 (range, 5–49). The median age at
onset was 15.0, and the mode was 12.0. In sample 2, the mean age at BDD onset was 16.7
7.2 (range, 4–43). The median age at onset was 15.0, and the mode was 13.0. Figure 1
shows the distribution of age at onset in both studies. 66.3% of subjects in sample 1 and
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67.2% in sample 2 had BDD onset before age 18. The mean age at which subjects began to
dislike some aspect of their appearance (sub-clinical BDD) was 13.1 6.0 (range, 4 to 43) in
sample 1 and 12.6 5.4 (range, 4–30) in sample 2.
In sample 1, there was a higher proportion of females with early age at BDD onset (73.0%
vs. 54.8%; p=.014), but this was not the case in sample 2. Individuals with early-onset BDD
did not significantly differ from those with late-onset BDD on any other demographic
variables in either sample (Table 1).
There were more similarities than differences in clinical features among those with early-
versus late-onset BDD in both samples 1 and 2 (Table 1). However, those with early-onset
BDD were more likely to report a gradual onset of BDD (meaning that it took more than one
week for symptoms to become clearly significant) than those with late-onset (90.2% vs.
79.0%, p=.036 in sample 1 and 82.0% vs. 67.6%, p=.022 in sample 2). Contrary to our
hypothesis, severity of BDD as measured by scores on the BDD-YBOCS or BDD-PSR was
not associated with earlier onset of BDD. However, on another measure of BDD symptom
severity (the BDDE), those with earlier onset reported greater BDD severity than those with
later-onset BDD (100.2 12.1 vs. 87.7 21.5, p=.038) (the BDDE was used only in study 1).
Psychosocial functioning and quality of life were markedly poor in both groups, but,
contrary to our hypothesis, they were not significantly poorer in those with early-onset BDD
in either sample (Table 1). Those with earlier onset were more likely to report a history of
attempted suicide in sample 1 (30.3% vs. 14.5%, p=.021) and in sample 2 (29.6% vs. 16.7%,
p=.032); they were also significantly more likely to report a history of attempted suicide
specifically due to their BDD symptoms in sample 2 (20.8% vs. 6.4%, p=.005). A higher
proportion of those with early-onset BDD reported a history of suicidal ideation at a trend
level in sample 1 (81.1% vs. 69.4%, p=.060). They were also significantly more likely to
report a history of physical violence due to BDD (25.3% vs. 8.6%, p=.040) and a history of
psychiatric hospitalization (48.8% vs. 30.4%, p=.007) in sample 2.
In sample 1, participants with early-onset BDD had a greater number of lifetime comorbid
disorders on both Axis I (4.7 ± 1.8 vs. 3.8 ± 1.7, p=.002) and Axis II (1.0 ± 1.3 vs. 0.5 ± 0.8,
p=.001) (Table 2), as predicted. More specifically, those with early-onset BDD were more
likely to have any lifetime substance use disorder (59.0% vs. 32.3%, p<.001), including
lifetime alcohol use disorders (52.5% vs. 30.6%, p=.001) and lifetime non-alcohol substance
use disorders (43.4% vs. 16.1%, p<.001). Those with early-onset BDD were also
significantly more likely to have a lifetime eating disorder (anorexia nervosa or bulimia
nervosa; 20.5% vs. 6.5%, p=.040) and borderline personality disorder (15.5% vs. 1.6%, p=.
032). Significant differences were not found for any other individual Axis I or Axis II
disorders.
Among participants in sample 2, those with early-onset BDD were more likely to have a
lifetime anxiety disorder (61.6% vs. 47.4%, p=.038), lifetime social phobia (39.6% vs.
24.3%, p=.022), and a lifetime eating disorder (11.6% vs. 2.6%, p=.022). Significant
differences were not found for any other individual Axis I or Axis II disorders.
4. Discussion
In this study, we examined age at onset of BDD and clinical correlates of early-onset illness
in two samples of individuals with lifetime DSM-IV BDD. To our knowledge, this is the
first report of detailed information about age at onset and the first to examine clinical
correlates of age at onset in BDD. In addition, to our knowledge, the two samples described
in this study are the largest samples of clinically evaluated individuals with DSM-IV BDD
that have been studied.
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The mean, median, mode, and range of age at onset were remarkably similar in the two
samples. It is notable that approximately two-thirds of subjects in both samples in this study
had BDD onset before age 18. The most common age at onset was 12–13 years. Although
illness onset ranged from 4–43 and 5–49 across the two samples, BDD is usually a disorder
of child or adolescent onset. Much smaller studies have reported a mean age at BDD onset
of 17 to 20 [67–69].
It is interesting that no participant in either sample had onset of the illness after their 40s,
even though the later decades of life arguably represent a time when appearance concerns
become more legitimate (eg, in terms of hair loss, wrinkles, loss of muscularity, or overall
attractiveness). But if BDD has, in part, an evolutionary basis, which may relate to a desire
to attract mates [70–72], then its usual age of onset becomes more understandable. In
addition, body image is a very important aspect of psychological and interpersonal
development in adolescents [73], which may contribute to BDD’s typical onset during
adolescence. Furthermore, social status (including inclusion or exclusion from peer groups)
is critically important during this period [72]. Research is needed, however, to determine
why BDD usually onsets during early adolescence.
It is interesting that females were more likely than males to have early age at onset in sample
1 (although this difference was not found in sample 2). This gender difference is the
opposite of the male gender predominance that has been found in OCD [31,36]. However,
not all OCD studies have found this difference [22,35].
Contrary to our hypotheses that early-onset of BDD would be associated with more severe
BDD symptoms as well as poorer psychosocial functioning and quality of life, this study
found that BDD subjects with early-onset and late-onset illness were generally similar with
respect to BDD severity, psychosocial functioning, and quality of life, although BDD
severity was greater in the early-onset group on one of three BDD severity measures. The
finding that BDD severity did not significantly differ between groups on most measures
appears to conflict with data from OCD research which has found early age at onset to be
associated with greater OCD symptom severity [22,24,26,28,31,35,36]. However, this
finding is in accordance with one study on age at onset in social phobia [21] but conflicts
with one other social phobia study [20]. The finding, however, that early age at BDD onset
was not significantly associated with poorer functioning or quality of life is consistent with
some OCD research [22,37].
One possible explanation for these apparent differences between BDD and studies of OCD
is that BDD is a different disorder than OCD, with important differences in clinical features
[34] and other aspects of the illness; thus, the same findings should not necessarily be
expected in studies of BDD. Another possible explanation for the discrepancies between this
study and the OCD literature may be due to the variability in defining age at onset and early-
onset in OCD studies. Age at onset has been defined as the age when symptoms begin
[26,74], the age at which the person displays significant distress or impairment [36], or the
age when the person first meets DSM-IV criteria [27]. In our study, we used the last
approach to classify our subjects. Without consistent definitions regarding age at onset
phenotypes, comparisons between research studies of early and later onset of illness are
hindered.
Some of the comorbidity findings differed between the two samples; reasons for this are
unclear, although one sample was assessed using DSM-IV criteria and the other largely with
DSM-III-R criteria. Nonetheless, our findings offer some support for our hypothesis that
early-onset BDD would be associated with greater psychiatric comorbidity. In sample 1,
early-onset BDD subjects had a greater number of comorbid Axis I and Axis II disorders,
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and they were more likely to have an eating disorder, any substance use disorder, an alcohol
use disorder, a non-alcohol use disorder, panic disorder, and borderline personality disorder.
Although the total number of comorbid disorders in sample 2 was not significantly greater in
the early-onset group, those with early-onset BDD were significantly more likely to have
several individual disorders. The markedly higher rates of lifetime substance use disorders in
early-onset subjects in sample 1 (for example, 59.0% had a lifetime substance use disorder)
is worth noting. Previous research suggests that BDD contributes to substance use disorders,
with 68% of individuals with both BDD and a substance use disorder reporting that BDD
contributed to their substance use [75]. If BDD in fact does contribute to the development of
problematic substance use in many individuals with BDD, then one might expect that the
earlier the onset of BDD, the more years a person with BDD has to develop a substance use
disorder.
In both studies, early onset was significantly associated with a history of suicide attempts
and with a history of suicide attempts due to BDD in sample 2. Nearly twice as many
individuals with early-onset BDD had attempted suicide, although effect sizes were in the
small to medium range. The association between age at onset and suicidality has been
assessed in some previous non-BDD studies, which found that early age at disorder onset is
associated with greater suicidality (see eg [8,76–79]. However, suicidality has received little
attention in the age at onset literature and should be a focus of future studies, given its
clinical importance.
This study has several limitations. Although the use of 18 years as a cutpoint for defining
“early-onset” is consistent with much prior research in other disorders [9,11,17,23,35], other
age cutpoints are sometimes used (eg [8,24,35]). In addition, subgroups within the early-
onset age cohort may exist (eg, prepubertal youth may differ from older adolescents); future
research should explore the possible heterogeneity of this early-onset group. In addition,
onset of BDD was retrospectively ascertained in this study based on subjects’ recollections.
Although the interviewers took great care to ascertain age at onset as accurately as possible,
it can be difficult to remember the details of an event that occurred, on average, decades
earlier, and some of our subjects may not have accurately recalled age of BDD onset.
Prospective, longitudinal studies in high-risk samples are needed to address this limitation in
the age at onset literature (see eg [80] for a study involving a prospective, high-risk design).
Strengths of the study include examination of two different clinically interviewed, large
samples that were ascertained differently, examination of a broad range of clinically
important variables, and use of both self-report and interviewer-administered measures with
strong psychometric properties and established norms.
There are several clinical implications of this study. The primary one is that clinicians
should be aware that BDD is primarily a disorder of childhood or adolescence onset, and
that subclinical BDD symptoms begin, on average, several years before individuals
experience the full-fledged disorder. In addition, a history of suicide attempts and
comorbidity, and possibly other features reflecting greater morbidity, are more common in
the early age at onset group. Early screening and intervention efforts targeting children and
adolescents with BDD are needed. For clinicians who work with adults, it is important to be
aware that this disorder has likely been present since childhood or adolescence and that
possible negative effects on attainment of developmental transitions and tasks may be an
important part of the case conceptualization and treatment plan.
Although early age at onset was not associated with significantly poorer psychosocial
functioning or quality of life at the time of assessment, the disorder may have a critical
impact on other areas of development that were not assessed in this study [81].
Developmental transitions and tasks during adolescence include affiliation transitions
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(greater autonomy from the family, peer affiliations, development of romantic affiliations),
achievement transitions (eg, school and work), and identity transitions (eg, changes in self-
definition) [82–85]. Severe psychopathology may adversely affect key developmental
transitions [81]. Such failures may have adverse repercussions throughout life [86]. Future
studies of age at onset in BDD, an often-severe disorder, should examine these important
constructs.
Acknowledgments
This study was supported by grant from the National Institute of Mental Health (R01 MH60241 and 5 K24
MH063975)) to Katharine A. Phillips, M.D.
The authors wish to thank Martha Niemiec for her invaluable assistance with manuscript preparation.
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Figure 1.
BDD Age at Onset in Two Samples
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Table 1
Demographic and Clinical Characteristics of Individuals with Early-Onset BDD vs. Late-Onset BDD
Variablea
Sample 1 Sample 2
BDD onset
before age 18
(n=122)
BDD onset
age 18 or
older (n=62) Wald or t p Effect sizebBDD onset
before age 18
(n=164)
BDD onset
age 18 or
older (n=80)
Chi
square or
tpEffect sizeb
Demographics
Gender (% female) 89 (73.0) 34 (54.8) 6.09 .014 .18 84 (51.2) 46 (57.5) 0.85 .356 .06
Age 33.8 ± 12.3 34.6 ± 9.8 −0.45 .632 .07 32.6 ± 10.9 32.4 ± 8.0 0.23 .818 .03
Minority (non-white or Hispanic) 22 (19.1) 6 (10.2) 2.32 .128 .12 8 (14.8) 2 (8.0) *
c
.490 .10
Single 95 (77.9) 40 (64.5) 3.75 .053 .14 132 (80.5) 65 (81.3) 0.02 .887 .01
Education (at least some college) 94 (77.0) 48 (77.4) 0.00 .955 .00 121 (80.7) 63 (82.9) 0.17 .684 .03
Currently employed (full or part time) 80 (65.6) 36 (58.1) 1.00 .319 .07 61 (53.0) 32 (51.6) 0.03 .856 .01
Course of BDD
Age at onset of BDD 12.8 ± 2.4 24.2 ± 7.7 −15.07 <.001 .55 12.8 ± 3.0 24.6 ± 6.6 −15.23 <.001 1.68
Duration of BDD (years) 20.3 ± 12.7 10.1 ± 7.5 6.29 <.001 .18 19.2 ± 11.6 7.8 ± 6.6 9.59 <.001 .99
Continuous course of illness
d
94 (77.7) 53 (85.5) 1.65 .199 .58 (.25–1.33) 139 (85.3) 66 (84.6) 0.02 .893 .01
Gradual BDD onset
e
110 (90.2) 49 (79.0) 4.41 .036 2.54 (1.06–6.08) 140 (82.0) 58 (67.6) 5.22 .022 .16
Symptom severity (current)
BDD-YBOCS 30.9 ± 6.3 29.3 ± 6.9 1.35 .181 .00 31.1 ± 5.5 30.9 ± 6.5 0.25 .803 .03
BDD PSR 5.7 ± 0.7 5.8 ± 0.7 −0.03 .974 .02 ---
f
--- --- --- ---
BDDE 100.2 ± 12.1 87.7 ± 21.5 2.11 .038 .12 ---
f
--- --- --- ---
BABS 16.1 ± 5.7 16.5 ± 5.2 −0.37 .712 .01 15.8 ± 5.0 17.5 ± 4.7 −1.61 .111 .37
HAM-D (24 item) 16.5 ± 10.9 16.9 ± 10.6 −0.27 .791 .01 19.8 ± 8.1 19.4 ± 6.3 0.23 .819 .05
Quality of life (current)
SF 36
Mental health 41.2 ± 18.7 39.9 ± 20.0 .13 .898 .00 36.6 ± 20.4 38.0 ± 15.2 −0.29 .775 .07
Role emotional 25.7 ± 35.4 23.1 ± 34.8 .27 .787 .01 29.4 ± 39.0 28.8 ± 37.5 .06 .955 .02
Social functioning 44.2 ± 25.0 45.8 ± 28.0 −0.60 .551 .00 40.4 ± 27.0 34.1 ± 23.2 0.95 .346 .25
Q-LES-Q 50.4 ± 16.0 49.0 ± 17.4 0.35 .730 .02 ---
f
--- --- --- ---
Functional impairment (current)
g
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Variablea
Sample 1 Sample 2
BDD onset
before age 18
(n=122)
BDD onset
age 18 or
older (n=62) Wald or t p Effect sizebBDD onset
before age 18
(n=164)
BDD onset
age 18 or
older (n=80)
Chi
square or
tpEffect sizeb
LIFE-RIFT 14.0 ± 3.4 13.5 ± 3.5 1.15 .252 .00 ---
f
--- --- --- ---
SAS-SR 2.4 ± 0.5 2.3 ± 0.5 1.20 .234 .00
f
--- --- --- ---
GAF 45.6 ± 10.3 45.7 ± 12.1 −0.49 .625 .02 51.7 ± 12.6 50.4 ± 8.5 0.57 .570 .12
SOFAS 48.6 ± 11.7 47.8 ± 15.2 0.19 .853 .04 ---
f
--- --- --- ---
Not working due to psychopathology 42 (34.4) 21 (33.9) 0.11 .745 .89 (.44–1.80) ---
f
--- --- --- ---
Not in school due to psychopathology 38 (31.1) 16 (25.8) 0.20 .657 .85 (.41–1.75) ---
f
--- --- --- ---
Social and occupational impairment due to
BDD (lifetime) 6.2 ± 1.6 5.9 ± 1.9 0.99 .325 .02 5.6 ± 1.8 5.1 ± 1.6 1.58 .116 .24
Suicidality (lifetime)
Suicidal ideation 99 (81.1) 43 (69.4) 3.54 .060 .50 (.24–1.03) 125 (83.9) 59 (79.7) 0.59 .441 .05
Suicidal ideation due to BDD 67 (54.9) 33 (53.2) 0.47 .490 .80 (.42–1.51) 112 (70.4) 57 (73.1) 0.18 .673 .03
Attempted suicide 37 (30.3) 9 (14.5) 5.36 .021 .38 (.17–.86) 47 (29.6) 13 (16.7) 4.60 .032 .14
Attempted suicide due to BDD 14 (11.5) 6 (9.7) 0.47 .495 .70 (.25–1.97) 33 (20.8) 5 (6.4) 8.00 .005 .18
History of physical violence 29 (23.8) 11 (17.7) 1.82 .177 .57 (.26–1.28) 18 (22.8) 7 (20.0) 0.11 .740 .03
History of physical violence due to BDD 26 (21.3) 12 (19.4) 0.72 .396 .70 (.32–1.58) 20 (25.3) 3 (8.6) 4.22 .040 .19
Psychiatric hospitalization (lifetime) 47 (38.5) 22 (35.5) 0.43 .511 .80 (.42–1.54) 79 (48.8) 24 (30.4) 7.34 .007 .17
a
Results are presented as n (%) or mean ± standard deviation.
b
Effect sizes for sample 1 are presented as odds ratio for logistic regressions or adjusted R2 for linear regressions. Effect sizes for sample 2 are presented as Cramer’s V for chi square analyses (.02 = small
effect, .03 = medium effect and .05 = large effect) and Cohen’s d for t-tests (.02 = small effect, .05 = medium effect, .08=large effect).
c
Fishers exact test
d
Symptoms had not remitted for at least 1 month since onset; assessed retrospectively.
e
It took longer than 1 week for symptoms to go from nonexistent to meeting clinical threshold.
f
--- = This measure was either not used in this sample or there exist too few observations to merit the inclusion of analyses.
g
On the LIFE-RIFT and SAS-SR, higher scores indicate poorer functioning; on the GAF and SOFAS, lower scores indicate poorer functioning
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Table 2
DSM-IV Axis I and Axis II Comorbidity in Individuals with Early-Onset vs. Late-Onset BDD
Variablea
Sample 1 Sample 2
BDD onset
before age 18
(n=122)
BDD onset
age 18 or
older (n=62) Wald or t p Effect sizebBDD onset
before age 18
(n=164)
BDD onset
age 18 or
older (n=80)
Chi
square or
tpEffect sizeb
Number of Comorbid Axis I disorders
c
4.7 ± 1.8 3.8 ± 1.7 3.01 .002 .040 2.9 ± 1.9 2.5 ± 1.4 1.68 .129 .24
Lifetime mood disorders 104 (85.2) 50 (80.6) 0.53 .468 .74 (.33–1.68) 133 (81.1) 66 (86.8) 1.21 .271 .07
Major depressive disorder 88 (72.1) 48 (77.4) 0.85 .358 1.41 (.68–2.92) 123 (75.5) 62 (82.7) 1.54 .214 .08
Bipolar disorder 13 (10.7) 2 (3.2) 3.08 .079 .25 (.05–1.18) 8 (7.9) 2 (4.2) *
d
.502 .07
Lifetime anxiety disorders 88 (72.1) 41 (66.1) 0.55 .458 .43 (.18–1.02) 101 (61.6) 36 (47.4) 4.29 .038 .13
Panic disorder 32 (26.2) 8 (12.9) 3.71 .054 .82 (.37–1.80) 25 (15.3) 8 (10.7) 0.94 .333 .06
Agoraphobia 1 (0.8) 1 (1.6) 0.47 .492 2.67 (.16–43.88) 2 (1.2) 3 (4.0) *
d
.181 .09
Social phobia 47 (38.5) 23 (37.1) 0.01 .905 .96 (.51–1.83) 65 (39.6) 18 (24.3) 5.26 .022 .15
Specific phobia 25 (20.5) 10 (16.1) 0.29 .591 .80 (.35–1.81) 17 (10.4) 6 (8.1) 0.31 .576 .04
Obsessive-compulsive disorder 43 (35.2) 20 (32.3) 0.44 .508 .80 (.41–1.55) 52 (31.9) 16 (21.6) 2.63 .105 .11
Posttraumatic-stress disorder 11 (9.0) 4 (6.5) 0.17 .683 .79 (.23–2.60) ---
e
--- --- --- ---
Lifetime substance use disorders 72 (59.0) 20 (32.3) 13.98 <.001 .27 (.13–.54) 39 (38.6) 14 (29.2) 1.27 .260 .09
Alcohol use disorders 64 (52.5) 19 (30.6) 10.69 .001 .31 (.16–.63) 23 (22.8) 9 (18.8) 0.31 .576 .05
Non-alcohol substance use disorders 53 (43.4) 10 (16.1) 14.23 <.001 .22 (.10–.48) 27 (27.0) 9 (18.8) 1.20 .273 .09
Lifetime eating disorder (anorexia and bulimia
only) 25 (20.5) 4 (6.5) 4.21 .040 .31 (.10–.95) 19 (11.6) 2 (2.6) 5.22 .022 .15
Anorexia nervosa 15 (12.3) 3 (4.8) 1.81 .179 .41 (.11–1.50) 6 (3.7) 0 (0.0) *
d
.181 .11
Bulimia nervosa 11 (9.0) 1 (1.6) 2.30 .130 .20 (.03–1.60) 14 (8.6) 2 (2.7) *
d
.159 .11
Lifetime somatoform disorders 1 (0.8) 2 (3.2) 1.88 .170 5.50 (.48–62.74) 0 (0.0) 0 (0.0) *
d
1.000 .00
Number of comorbid Axis II disorders 1.0 ± 1.3 0.5 ± 0.8 3.30 .001 .048 1.1 ± 1.5 0.7 ± 1.3 1.00 .322 .29
Paranoid personality disorder 14 (12.1) 2 (3.2) 3.46 .063 .23 (.05–1.08) 1 (5.3) 0 (0.0) *
d
1.000 .15
Schizoid personality disorder 3 (2.6) 1 (1.6) 0.32 .568 .51 (.05–5.23) 0 (0.0) 0 (0.0) *
d
1.000 .00
Schizotypal personality disorder 4 (3.4) 0 (0.0) .00 .997 .00 (.00–undef
f
)0 (0.0) 0 (0.0) *
d
1.000 .00
Antisocial personality disorder 8 (6.9) 3 (4.8) 1.02 .312 .48 (.12–1.98) 0 (0.0) 0 (0.0) *
d
1.000 .00
Borderline personality disorder 18 (15.5) 1 (1.6) 4.61 .032 .11 (.01–.82) 0 (0.0) 0 (0.0) *
d
1.000 .00
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Bjornsson et al. Page 18
Variablea
Sample 1 Sample 2
BDD onset
before age 18
(n=122)
BDD onset
age 18 or
older (n=62) Wald or t p Effect sizebBDD onset
before age 18
(n=164)
BDD onset
age 18 or
older (n=80)
Chi
square or
tpEffect sizeb
Histrionic personality disorder 1 (0.9) 0 (0.0) 0.00 .997 .00 (.00–undef
f
)0 (0.0) 0 (0.0) *
d
1.000 .00
Narcissistic personality disorder 5 (4.3) 0 (0.0) 0.00 .997 .00 (.00–undef
f
)1 (5.3) 2 (15.4) *
d
.552 .17
Avoidant personality disorder 33 (28.4) 12 (19.4) 2.39 .122 .54 (.25–1.18) 7 (36.8) 4 (30.8) *
d
1.000 .06
Dependent personality disorder 5 (4.3) 2 (3.2) .02 .881 .88 (.16–4.80) 2 (10.5) 0 (0.0) *
d
.502 .21
Obsessive-compulsive personality disorder 20 (17.2) 4 (6.5) 3.09 .079 .36 (.12–1.13) 1 (5.3) 1 (7.7) *
d
1.000 .05
a
Results are presented as n (%) or mean ± standard deviation.
b
Effect sizes for sample 1 are presented as Odds Ratio for logistic regressions or Adjusted R2 for linear regressions. Effect sizes for sample 2 are presented as Cramers V for chi square analyses (.02 = small
effect, .03 = medium effect and .05 = large effect) and Cohens d for t-tests (.02 = small effect, .05 = medium effect, .08=large effect).
c
There were more disorders assessed in sample 1 than in sample 2; therefore number of comorbid disorders in the two studies should not be directly compared.
d
Fishers exact test
e
This disorder was not assessed in sample 2.
f
undef = the upper limit is undefined because one of the groups did not have the disorder; thus, the upper limit could not be calculated.
Compr Psychiatry
. Author manuscript; available in PMC 2014 October 01.