Relationship between social anxiety disorder and body dysmorphic disorder
Research highlights
►SAD and BDD are highly comorbid. ►SAD and BDD share similarities in clinical features and cognitive biases. ►SAD and BDD have cross-cultural similarities and respond to similar treatments.
Section snippets
Definition of SAD
SAD is one of the most common psychiatric conditions. The epidemiological literature reports lifetime prevalence rates of SAD in Western countries ranging between 7% and 12% of the population (Furmark, 2002, Kessler et al., 2005). The disorder affects men and women relatively equally as evaluated in community studies. SAD often begins in the mid-teens, but can also occur in early childhood. During childhood, SAD is often associated with shyness, behavioral inhibition, overanxious disorder,
Definition of BDD
Although cases of “imagined ugliness” have been documented for centuries, BDD has only recently begun to receive empirical attention (Phillips, 2005). Introduced to the DSM-III in 1980, such over-concern with physical appearance was termed “dysmorphophobia,” which was categorized as an atypical somatoform disorder (American Psychiatric Association, 1980). The construct was re-labeled and retained in the DSM-III-R as “body dysmorphic disorder,” in part due to controversy surrounding the
Comorbidity
Studies have shown that among individuals with a lifetime diagnosis of SAD (generalized or non-generalized subtypes), 52–80% have a lifetime diagnosis of at least one other psychiatric disorder (Chartier et al., 2003, Grant et al., 2005, Merikangas and Angst, 1995, Ruscio et al., 2008). Approximately one-third to three-quarters of individuals with the generalized subtype of SAD meet diagnostic criteria for another lifetime disorder (Chartier et al., 2003, Kessler et al., 1998, Stein et al., 1990
Cognitive biases
Available research evidence demonstrates that individuals with a generalized subtype of SAD and BDD tend to display negative interpretation biases for ambiguous social information (Amir et al., 1998, Buhlmann et al., 2002, Heinrichs and Hofmann, 2001, Hofmann, 2007). For example, one study recruited 32 treatment-seeking individuals with generalized SAD and administered a questionnaire, which measured their interpretations to 22 social and non-social scenarios (Amir et al., 1998). Participants
Treatment outcome
Previous studies strongly support that cognitive and behavioral interventions are efficacious for treating both SAD and BDD (Hofmann, 2007, Hofmann and Otto, 2008, Hofmann and Smits, 2008, Neziroglu and Khemlani-Patel, 2002). The cognitive-behavioral therapy (CBT) rationale is remarkably similar for treating both disorders by emphasizing the role of maladaptive cognitions and avoidance in maintaining anxiety. Common components of treatment include psychoeducation, cognitive restructuring of
Cross-cultural aspects
In some Eastern cultures, BDD is conceptualized as an offensive subtype of SAD (Lewis-Fernandez et al., 2010). For example, the Japanese conceptualization of SAD is referred to as taijin kyofusho (TKS) or literally, “fear of interpersonal relations” in Japanese (Suzuki, Takei, Kawai, Minabe, & Mori, 2003). TKS is similar to SAD in that the patient is primarily concerned with being observed by others and avoids social situations as a result. Both disorders therefore consist of egocentric social
Discussion
Similarities between SAD and BDD in phenomenology, cognitive biases, cross-cultural manifestations, and treatment response suggest that these two disorders share common pathological aspects. BDD is defined as a preoccupation with an imagined defect in physical appearance. This concern is likely associated with fear of negative evaluation by others, directly linking it with the defining feature of social anxiety disorder. Our review supports the notion that BDD is a form of anxiety disorder that
Acknowledgements
Angela Fang and Stefan G. Hofmann, Department of Psychology at Boston University. Dr. Hofmann is a paid consultant of Merck/Schering-Plough for issues unrelated to this study. The work has been partly supported by NIMH grants MH-078308 and MH-081116.
The authors acknowledge the DSM-V Anxiety, Obsessive–Compulsive Spectrum, Post-Traumatic, and Dissociative Disorders Work Group and advisors to the workgroup for their contributions to the discussions of the material covered herein. Dr. Hofmann is
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