Obsessive-Compulsive Disorder After Body Dysmorphic Disorder: A Report of 2 Cases (a man and his mother)

Sir: Body dysmorphic disorder (BDD), or dysmorphophobia, is a mental disorder characterized by preoccupation with an imagined defect in one's appearance. Alternatively, BDD may involve a minor physical abnormality, but the concern is regarded as grossly excessive.¹ Most patients with BDD show repetitive behaviors, such as mirror checking, requests for reassurance, and skin picking, which resemble obsessive-compulsive disorder (OCD) compulsions. Studies using psychometric scales found that dysmorphophobic patients were more “obsessoid” and reported higher scores on the Leyton Obsessional Inventory than healthy controls.²

High lifetime OCD rates (34%–78%) have been found in several samples of BDD patients.^3,4 Conversely, lifetime BDD rates in patients with OCD also appear to be high, with reported rates ranging from 8%⁵ to 37%.⁴ OCD has been found to be the most common disorder in relatives of patients with BDD.⁴ Hypochondriasis and pathologic grooming occurred more frequently in relatives of probands with OCD, whether or not probands also had the same diagnosis.⁶ With respect to a familial relationship between OCD and obsessive-compulsive spectrum disorders, research suggests a shared etiology between OCD and hypochondriasis, body dysmorphic disorder, and grooming disorders.

The obsessive-compulsive spectrum was proposed in response to observations that a number of disparate disorders (for example, body dysmorphic disorder, hypochondriasis, some eating disorders, and some impulse-control disorders) share obsessive-compulsive features—that is, they are marked by obsessive thinking and/or compulsive behavior.^7–9 As regards treatment outcome, BDD, like OCD, appears to respond to selective serotonin reuptake inhibitors and clomipramine^10,11 and to exposure and response prevention.^12,13 Similarities in patient characteristics, course, comorbidity, neurobiology, and treatment response provide further support for the notion that these disorders may have a special relationship and thus should be conceptualized as a spectrum of related disorders.

Some important differences between BDD and OCD, however, have been reported. First and foremost, it seems that beliefs about appearance that underlie BDD preoccupations generally involve poorer insight than observed in beliefs underlying OCD obsessions. BDD preoccupations frequently lose their ego-dystonic character, become more similar to over-valued ideas than obsessions, and may even develop into full-blown delusional thinking.¹⁴ Dysmorphic concerns are experienced as more natural than intrusive and are accepted and held with a significant degree of conviction rather than regarded as senseless, and patients often acquiesce to them without much resistance.¹⁵

Herein, we report 2 cases (a man and his mother) indicating similarities consistent with the literature, including heredity pattern, comorbidity, and treatment response between BDD and OCD.

Case 1. Mr. S, a 46-year-old male civil servant, presented to our clinic with the fear of being murdered. His complaint had started 3 months ago. While he was assessing the applications for a free health insurance card in his office, he was confronted with a written application that was sent from a farmer whose application had previously been rejected. The farmer wrote that his property should be evaluated again. After reading it, Mr. S thought that the farmer would kill him if he had signed the application. He was sure that it was illogical to think like that, but he could not erase the idea of being murdered from his mind. After a few days, he was not able to think about anything except being murdered. Although he had known that he had not signed the application and it was impossible for him to be held responsible for anything, he continued to ruminate about the idea. He even visited the farmer and heard from him that he would certainly not kill him. However, his feeling of reassurance lasted only a few minutes, and his anxiety grew day by day. He was extremely frightened when first seen in our clinic. According to DSM-IV criteria, he received a diagnosis of OCD because of his obsession (an intrusive and recurrent persistent thought that caused marked anxiety and affected his occupational functioning significantly). After the treatment with clomipramine 75 mg/daily for the first 12 days and then 150 mg/daily for 2 months, his complaints ceased gradually.

Mr. S's psychiatric history was as follows: he was a brilliant student until, while he was in high school at age 15, he started to think that his nose was large and ugly. Although his friends and family struggled to convince him that his nose was not so big and was, in fact, in harmony with his face, he was so preoccupied with his nose that he would not listen to anybody. Finally, he dropped out of school for fear of being scrutinized and talked about by his classmates. Fortunately, he was convinced by the plastic surgeon to whom he applied for the reconstruction of his nose to visit a psychiatrist. He received a diagnosis of BDD according to DSM-IV criteria from the psychiatrist, and after 4 months of receiving clomipramine 75 mg/day, a marked improvement in his condition was noted. His thoughts about having an ugly nose disappeared completely.

Case 2. Mr. S's mother, Mrs. A, a homemaker aged 66 years, had a similar history. When she was 14 years old, she was convinced that her face was extremely asymmetric and that everybody around her felt that she was disgusting. Until she was forced to see a psychiatrist, she did not leave the house for 4 months. She received a diagnosis of BDD and was prescribed clomipramine 75 mg daily and was courageous enough to leave the house 2 months after the beginning of treatment. As interestingly similar to Mr. S's history, when she was 47 years old, she thought, after buying a TV, that the invoice paper she had signed made her a debtor to the TV seller not only for the TV but also for everything she had. She was sure that she did not sign anything else and the seller tore the invoice to pieces, but nothing made her feel reassured. She was afterwards suspicious about signing papers that made her a debtor to anyone she talked with, and she could not make conversation without asking, “Have I signed any paper?” although she was sure that her thought was illogical. Every conversation she had ended with this question. She admitted a need for psychiatric help and received a diagnosis of OCD according to DSM-IV criteria, as she had an obsession (about being a debtor) that was accompanied by a verbal compulsion. She was prescribed clomipramine 150 mg/daily for 2 months before she voiced an acceptable improvement. She has been taking clomipramine in variable doses for 19 years. Her compulsion has disappeared completely, while her intrusive thoughts occasionally arise.

OCD and BDD might frequently coexist in clinical samples and have several similarities,¹⁶ including prominent obsessions and compulsions and similarities in treatment response. However, some differences also exist. For example, studies have found that BDD subjects have a significantly poorer insight than OCD subjects, and a significantly greater percentage of BDD subjects than OCD subjects were classified as delusional.¹⁷ The poor insight generally characteristic of BDD may make it difficult to persuade patients to accept and remain in psychiatric treatment. Of interest, studies of both BDD and OCD have found that patients with poorer insight or even delusional thinking are as likely to respond to serotonin reuptake inhibitors (SRIs) as patients with better insight.¹⁸ Regarding response to cognitive-behavioral therapy (CBT), several studies have found that OCD with poor insight responds as well to behavior therapy as OCD with good insight.¹⁹ Descriptive studies have found that a higher proportion of BDD patients are unmarried, unemployed, and less educated¹⁶ and that BDD patients have a higher prevalence of major depression, social phobia, and suicidal ideation and suicide attempts attributed primarily to their disorder (i.e., BDD or OCD).²⁰

In our report, Mr. S and his mother, Mrs. A, had striking similarities. The beginning of BDD in both cases was in the early to middle teenage years. They both successfully responded to clomipramine in a few months. The age at onset of OCD was in the mid-40s for both the mother and the son. Clomipramine was again the excellent therapy choice. Mr. S's obsession—different from his mother's—was not associated with any compulsion and differentiated from delusion with the presence of insight. These findings lead us to emphasize the importance of hereditary relationship in and similarities, including treatment response and comorbidity, between BDD and OCD.

Studies from clinical settings tend to find higher comorbidity rates than studies from nonclinical settings because having more than one disorder may increase the probability of seeking treatment.²¹ However, comorbidity is the rule rather than the exception, as is the case for many psychiatric disorders. Clinicians need to be mindful of the possible clinical impact of comorbid conditions—for example, their association with greater morbidity and the need to consider comorbidity in treatment planning.

A small magnetic resonance imaging study (N = 16) found that BDD subjects had a leftward shift in caudate asymmetry and greater white matter volume than healthy controls, whereas some OCD studies have found the opposite (i.e., a rightward shift in caudate asymmetry and reduced white matter volume).²² BDD and OCD both appear to respond preferentially to SRIs,^23,24 but preliminary data suggest that, unlike OCD, BDD may not respond to SRI augmentation with antipsychotics.^25,26 However, additional research is needed to further examine the nature of BDD's relationship to OCD.

Taken together, these findings give some support to the hypothesis that BDD may be related to OCD and is an “OCD-spectrum disorder,” but that BDD and OCD are not identical. There is also a need for future studies to evaluate evidence from other sources, such as neurobiological, family, and treatment studies, to further our understanding of the concept of obsessive-compulsive spectrum disorders.