Traumatic Experiences in Individuals With Body Dysmorphic Disorder Ulrike Buhlmann, PhD, Luana M. Marques, PhD, and Sabine Wilhelm, PhD Abstract: Individuals with body dysmorphic disorder (BDD) are excessively concerned about perceived defects in their appearance (e.g., blemishes on their skin). BDD is a severe mental disorder often associated with increased sui- cidality as well as significant social and occupational interference (e.g., J Clin Psychiatry 2005;66:717Y725). Recently, investigators have begun to explore variables that might function as risk factors in the development of BDD, such as traumatic experiences (e.g., Child Abuse Negl 2006;30:1105Y1115). As such, one of the goals of the current study was to examine the role of early-life sexual, physical, or emotional abuse in BDD. Specifically, the Traumatic Stress Institute Life Event Questionnaire (Treat Abuse Today 1992;2:9Y11) was used to examine whether individuals with BDD (n = 18) self-reported having expe- rienced more traumatic events than mentally healthy controls (n = 19). The BDD group reported more retrospective experiences of sexual and physical abuse in childhood or adolescence than did healthy controls. Surprisingly, there was no significant group difference in reports of emotional abuse in early life. This study provides preliminary evidence of the importance of examining abuse as a potential risk factor in the development of BDD. Key Words: Body dysmorphic disorder, traumatic experience, sexual abuse, physical abuse, emotional abuse, body image. (J Nerv Ment Dis 2012;200: 95Y98) B ody dysmorphic disorder (BDD) is defined by perceived de- fects in one’s physical appearance, most commonly flaws in their face (e.g., acne, wrinkles, size or shape of the ears, eyes, or nose; American Psychiatric Association, 2000). Although the ‘‘flaw’’ is usually not noticeable to others, BDD sufferers misperceive the body areas of concern as unattractive and often repulsive and often spend up to several hours per day thinking about them. Associated features of BDD are frequent checking and/or avoidance of mirrors as well as excessive grooming behaviors (e.g., make-up application). Fre- quent asking for reassurance from others, comparing their appearance with that of others, and camouflaging the body part(s) of concern (e.g., wearing a hat to hide thinning hair) are also common. BDD is further associated with significant impairment in social and/or occu- pational functioning and poor quality of life (e.g., Phillips and Menard, 2006). In addition, the rates of suicide attempts are very high in BDD (Phillips and Menard, 2006; Phillips et al., 2005; Veale et al., 1996), further emphasizing the severity of this disorder. Given the severity of impairment and lethality concerns associ- ated with BDD, investigators have recently begun to examine variables that might function as risk factors in the development and/or mainte- nance of BDD. To that end, significant life events such as teasing and traumatic experiences have been postulated to contribute to the devel- opment or maintenance of appearance concerns (e.g., Feusner et al., 2010; Neziroglu et al., 2008; Wilhelm, 2006; Veale, 2004). To our knowledge, only a few studies have examined perceived teasing in BDD so far. Osman et al. (2004) assessed spontaneously occurring images in BDD. They found that most individuals with BDD reported having experienced frequent distressing images related to being bul- lied or teased because of their appearance (e.g., ‘‘I was ten years old and never got on with this boy in school. I remember one day asking him why he didn’t like me and he said, ‘it’s becauseyou are ugly.’’’). Furthermore, we examined perceived teasing in BDD and found that individuals with BDD reported more appearance- and competency- related teasing than did mentally healthy control participants. In addi- tion, appearance-related teasing was positively associated with BDD symptom severity (Buhlmann et al., 2007). We further investigated perceived appearance-related teasing in the German general population (Buhlmann et al., in press). Consistent with previous findings, we found that individuals with BDD reported significantly more teasing than did non-BDD individuals. In addition, they remembered the teasing ex- perience more vividly and as more traumatic, relative to individuals without BDD, providing further evidence for perceived teasing in BDD. Further, research on the associations between specific trau- matic experiences and BDD is also very limited. This is surprising given that previous research found an association between childhood abuse and body dissatisfaction among individuals with other body concerns such as people with diagnoses of eating disorders (e.g., Attias and Goodwin, 1999; Byram et al., 1995; Waller et al., 1993). In fact, to our knowledge, only two studies have examined the role of traumatic events in BDD (Didie et al., 2006; Neziroglu et al., 2006). Didie et al. (2006) examined the relationship between different types of child- hood neglect and abuse and BDD symptoms among 75 individuals with current or past BDD. The results from that study suggested that most individuals with BDD in their sample (78.7%) reported a history of childhood maltreatment. Further analyses indicated that emotional neglect (68.0%), emotional abuse (56.0%), physical abuse (34.7%), physical neglect (33.3%), and sexual abuse (28.0%) were common in BDD. In addition, Didie et al. (2006) reported that individuals who reported a traumatic history (e.g., emotional, physical, and sexual abuse) were also more likely to have a history of suicide attempt, thus lending further support to the reported high suicidal concerns amongst BDD sufferers. One of the limitations of this investigation, as described by the authors, was the lack of a healthy control group, which could have helped them understand whether these findings were significantly different from the general population and not only an artifact of their sample selection. Neziroglu et al. (2006) examined the rates of abuse in BDD (n = 50) and obsessive-compulsive disorder (OCD; n = 50). Over- all, they found that 38% of individuals with BDD reported a history of childhood abuse, relative to 14% of individuals with OCD. They further found that individuals with BDD, relative to individuals with OCD, had significantly higher rates of self-reported emotional (28% vs. 2%) and sexual abuse (22% vs. 6%). Unfortunately, both studies did not include a mentally healthy control group. Consequently, the current study was designed to address this limitation. In summary, past research suggests that BDD is a disabling mental disorder, which has been associated with significant social and BRIEF REPORT The Journal of Nervous and Mental Disease & Volume 200, Number 1, January 2012 www.jonmd.com 95 Massachusetts General Hospital and Harvard Medical School, Boston, MA. Send reprint requests to Sabine Wilhelm, PhD, Massachusetts General Hospital, Body Dysmorphic Disorder Clinic, Department of Psychiatry, Harvard Medical School, 185 Cambridge Street, Boston, MA 02114. E-mail: wilhelm@psych.mgh.harvard.edu. Copyright * 2012 by Lippincott Williams & Wilkins ISSN: 0022-3018/12/2001<0095 DOI: 10.1097/NMD.0b013e31823f6775 Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.