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Journal of Clinical Child & Adolescent Psychology

ISSN: 1537-4416 (Print) 1537-4424 (Online) Journal homepage: https://www.tandfonline.com/loi/hcap20

Sex Differences in the Presentation of Body Dysmorphic Disorder in a Community Sample of Adolescents

Sophie C. Schneider, Jonathan Mond, Cynthia M. Turner & Jennifer L. Hudson

To cite this article: Sophie C. Schneider, Jonathan Mond, Cynthia M. Turner & Jennifer L. Hudson (2019) Sex Differences in the Presentation of Body Dysmorphic Disorder in a Community Sample of Adolescents, Journal of Clinical Child & Adolescent Psychology, 48:3, 516-528, DOI: 10.1080/15374416.2017.1321001

To link to this article: https://doi.org/10.1080/15374416.2017.1321001

Published online: 25 May 2017.

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OBSESSIVE-COMPULSIVE AND RELATED DISORDERS

Sex Differences in the Presentation of Body Dysmorphic Disorder in a Community Sample of

Adolescents

Sophie C. Schneider Department of Psychology, Macquarie University

Jonathan Mond School of Medicine, Western Sydney University and School of Health Sciences, University of

Tasmania

Cynthia M. Turner School of Psychology, Australian Catholic University

Jennifer L. Hudson Department of Psychology, Macquarie University

The current study sought to explore sex differences in the presentation of probable full-syndrome and subthreshold body dysmorphic disorder (BDD) in adolescents from an Australian community sample. Specifically, it examined sex differences in the types of BDD symptoms endorsed, body areas of concern, and the association with elevated symptoms of comorbid disorders. In male participants, it also compared the presenting features of those with and without muscle dysmorphia. Of 3,149 adolescents assessed using self-report questionnaires, 162 (5.1%) reported probable BDD (57.4% male, Mage = 14.89 years, SD = 1.33, primarily from Oceanian or European cultural backgrounds). All participants completed measures of BDD symptoms; past mental health service use; and symptoms of anxiety, depression, obsessive-compulsive disorder, and eating disorders. Male participants completed additional measures of quality of life, drive for muscularity, hyper- activity, conduct disorder, peer problems, and emotional symptoms. Controlling for demographic variables that varied by sex, male and female participants reported similar BDD symptom severity, rates of most elevated comorbid symptoms, and mental health service use. Concerns regarding muscularity, breasts/nipples, and thighs differed by sex. Female participants were more likely than male participants to report elevated generalized anxiety symptoms. In male participants, muscle dysmorphia was not associated with greater severity across most measures. The presenting features of BDD were broadly similar in male and female participants, and in male participants with and without muscle dysmorphia. Future research should seek to increase mental health service use in adolescents with BDD and to improve rates of disorder detection in clinical settings.

INTRODUCTION

Body dysmorphic disorder (BDD) involves preoccupation with perceived defects in appearance that appear minimal, or nonexistent, to others (American Psychiatric Association, 2013). BDD typically begins in adolescence; the mean age

Correspondence should be addressed to Jennifer L. Hudson, Centre for Emotional Health, Department of Psychology, Macquarie University, Sydney, Australia 2109 E-mail: [email protected]

Journal of Clinical Child & Adolescent Psychology, 48(3), 516–528, 2019 Copyright © Society of Clinical Child & Adolescent Psychology ISSN: 1537-4416 print/1537-4424 online DOI: https://doi.org/10.1080/15374416.2017.1321001

of disorder onset is 16 years, with mean subclinical symp- tom onset at 13 years (Bjornsson et al., 2013; Marques et al., 2011b). BDD onset prior to age 18 is reported by 66.8% of adults and is associated with increased suicidality and comorbidity compared to those with adult onset (Bjornsson et al., 2013). As BDD is a potentially severe disorder that typically follows a chronic course without appropriate mental health treatment (Phillips, Menard, Quinn, Didie, & Stout, 2013), these difficulties are likely to persist into adulthood. These factors highlight the need for early detection and treatment of adolescent BDD (Fang & Wilhelm, 2015).

A serious barrier to the early detection of BDD is under diagnosis in routine clinical settings (Phillips & Feusner, 2010). Across four studies of adolescents and adults in psy- chiatric settings, standard clinical interviews detected just two of 71 (2.8%) cases of BDD subsequently identified using BDD-focused measures (Conroy et al., 2008; Dyl, Kittler, Phillips, & Hunt, 2006; Grant, Kim, & Crow, 2001; Veale, Akyüz, & Hodsoll, 2015). Individuals with BDD are unlikely to spontaneously disclose their BDD symptoms, which may be related to feelings of embarrassment or shame, or poor insight into their concerns (Buhlmann, 2011; Didie, Kelly, & Phillips, 2010; Marques, Weingarden, LeBlanc, & Wilhelm, 2011). This places a responsibility on the assessing clinician to probe for BDD and to be familiar with the symptomatol- ogy of BDD (Phillips & Feusner, 2010).

As there may be developmental differences in the fea- tures or impact of BDD (Phillips et al., 2006), it is important that clinicians are aware of the presentation of BDD in adolescents. Accordingly, several studies have provided information about the presenting features of adolescent BDD in clinical samples (Albertini & Phillips, 1999; Dyl et al., 2006; Greenberg, Mothi, & Wilhelm, 2016; Mataix- Cols et al., 2015; Phillips et al., 2006). However, it is unclear how representative these findings are of adolescents with BDD in the general community, as treatment seeking for BDD may be associated with greater symptom severity, increased comorbidity, or suicidality (Albertini & Phillips, 1999). Further, these clinical studies have involved just 126 adolescents with BDD, of whom only 24 (19.0%) were male. As the community prevalence of adolescent BDD appears to be similar across sex (Schneider, Turner, Mond, & Hudson, 2016b), it is unclear whether the underrepresen- tation of male adolescents in clinical samples may be due to lower treatment seeking, or gender-specific barriers in obtaining a diagnosis of BDD. Either way, existing research on the presentation of adolescent BDD is highly limited, and it is unclear how well female-dominated clinical sam- ples represent adolescents in the general community, and male BDD presentations in particular.

Sex differences in adolescent BDD should be explored, as some features of BDD differ between male and female individuals in adult clinical samples. Although overall BDD severity was similar between male and female participants

(Phillips & Diaz, 1997; Phillips, Menard, & Fay, 2006), male participants were more likely to be single and living alone than female participants, suggesting greater interfer- ence in romantic relationships (Phillips et al., 2006). Some BDD symptoms appeared to differ; male individuals were more likely to lift weights than female individuals, whereas female individuals were more likely to try to camouflage their appearance, pick their skin, and check the mirror excessively (Perugi et al., 1997; Phillips & Diaz, 1997; Phillips et al., 2006). Male individuals reported higher rates of lifetime substance use disorders than female indivi- duals, whereas female individuals reported higher rates of bulimia and generalized anxiety disorder than male indivi- duals (Perugi et al., 1997; Phillips & Diaz, 1997; Phillips et al., 2006). Some of the body areas of concern also differed by sex; male individuals were more likely to be concerned about their genitals, body build, and thinning hair, whereas female individuals were more likely to be concerned about weight, breasts/chest, hips, buttocks, thighs, legs, and other types of hair concerns (Perugi et al., 1997; Phillips & Diaz, 1997; Phillips et al., 2006).

In addition to a lack of research on sex differences in adolescent BDD, there has been little research concerning muscle dysmorphia, a subtype of BDD that affects male individuals almost exclusively where the individual is con- cerned about being insufficiently muscular or having a small body build (American Psychiatric Association, 2013). In male adults with BDD, those with muscle dysmorphia report poorer quality of life, greater suicidality, and higher prevalence of substance use disorder than those without muscle dysmorphia (Pope et al., 2005). Currently, it is unknown whether muscle dysmorphia is associated with a more severe BDD presentation in male adolescents. There is also substantial debate regarding the classification of muscle dysmorphia. Some researchers have suggested that it is a form of BDD reflecting Western masculine body image ideals (Kanayama & Pope, 2011), whereas others argue that it is better understood as an eating disorder (Murray, Griffiths, & Mond, 2016). A recent review reported that there is insufficient evidence to support any proposed clas- sification (Dos Santos Filho, Tirico, Stefano, Touyz, & Claudino, 2015). Therefore, not only is it important to determine whether muscle dysmorphia is associated with greater BDD severity for clinical reasons, but research com- paring the BDD presentation of male individuals with and without muscle dysmorphia may help to inform the current classification debate.

THE CURRENT STUDY

BDD is underdiagnosed in clinical settings, and there is limited information available to clinicians regarding the presentation of adolescent BDD. Further, it is unclear whether and to what extent findings from female-dominated

SEX DIFFERENCES IN ADOLESCENT BDD 517

clinical samples represent male and female adolescents with BDD in the general community. The aims of this study therefore were (a) to explore potential sex differences in the presenting features of BDD in adolescents from a com- munity sample, and (b) to compare the presentation of BDD in male individuals with and without muscle dysmorphia. Consistent with Dyl et al. (2006), we chose to include participants who screened positive both for probable full- syndrome BDD (pBDD) and subthreshold BDD (sBDD). Using the same sample, we have previously identified that pBDD and sBDD are associated with higher symptoms of depression, anxiety, and eating disorders and with higher rates of mental health service use than those without BDD (Schneider, et al., 2017; Schneider et al., 2016b). The pBDD and sBDD groups were therefore combined in the current study to identify participants with a broad range of BDD symptom severity and to increase statistical power for key analyses.

Based on the limited available evidence, it was hypothe- sized that male participants would report higher levels of interference with romantic relationships than female partici- pants and that female participants would report higher appearance checking than male participants. It was further hypothesized that female participants would be more likely than male participants to report elevated symptoms of eating disorders and generalized anxiety disorder. Certain body areas of concern were expected to vary by sex, with male participants predicted to report elevated concerns about muscularity, genitals, body build, and thinning hair and female participants to report elevated concerns about weight, breasts, hips, buttocks, thighs, legs, and other hair concerns. Female participants were expected to report higher levels of past mental health service use than male participants. Finally, male participants with symptoms of muscle dysmorphia were hypothesized to have poorer qual- ity of life, a greater number of body areas of concern, greater muscularity-related body image disturbance, and more muscularity-driven behaviors than male participants without muscle dysmorphia.

METHOD

Participants

Details of the study design and recruitment methods have been reported previously (Schneider et al., 2016b). Briefly, participants were recruited from seven high schools in the Greater Sydney area of New South Wales, Australia, that were taking part in two existing studies of emotional health in youth. Female adolescents were recruited from two inde- pendent and one government girls’ school participating in a study of the development and prevention of anxiety and depression. This study involved annual questionnaire assessments over a 4-year period and delivery of a

schoolwide preventative intervention for anxiety and depression. Male adolescents were recruited from four Catholic boys’ schools participating in a study of the utiliza- tion of an online treatment program for anxiety. This study involved up to 2 years of assessments, and students were given access to an online program to treat anxiety and depression. Data used in the current study came from the first assessment for each student. Of 5,005 students enrolled in eligible school grades at the time of testing, 3,149 (62.9%) consented to involvement in the larger study and provided sufficient information for BDD group categoriza- tion using the Body Dysmorphic Disorder Questionnaire– Adolescent Version (BDDQ-A; Phillips, 2005). Of the 2,000 male participants, 35 (1.8%) reported pBDD and 58 (2.9%) reported sBDD. Of the 1,149 female participants, 20 (1.7%) reported pBDD and 49 (4.3%) reported sBDD. Participants with pBDD and sBDD were combined, resulting in a final sample of 162 adolescents with pBDD or sBDD (57.4% male, Mage = 14.86, SD = 1.33, range = 12–18 years), hereafter referred to as having BDD.

Procedure

All assessments were conducted during school hours and were supervised by members of the research team. Students completed questionnaires using deidentified codes, and par- ticipants were informed that their responses were confiden- tial unless their responses indicated serious risk of harm. The research was approved by the Human Research Ethics Committee of Macquarie University, references 5201300531 and 5201100886, and by the governing bodies of each school.

All participants consented to involvement in the relevant larger study of emotional health, of which the current study was a part. Parents were provided with written information about the overall study and were asked to discuss participa- tion with their child. Students were also informed directly about the study, typically in school assemblies or class groups. At boys’ schools, opt-out parent consent was used, and if parents did not opt out, students provided active consent. At girls’ schools, opt-in parent consent was used, and all students had the opportunity to opt out of testing verbally. No incentives to participate were provided by the researchers; however, some schools provided incentives to students for the return of consent forms, regardless of the consent status.

Measures

Male and Female Participants

The BDDQ-A (Phillips, 2005) assesses BDD criteria according to the Fourth Edition of the the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 1994). To screen positive for BDD,

518 SCHNEIDER ET AL.

a participant must endorse excessive concern about appear- ance, associated distress or impairment, and report that their concerns are not primarily due to their weight or a fear of not being thin enough. Open text items also assess the body areas of concern, and the nature of any interference. Time spent thinking about appearance per day is also assessed; thinking about appearance for at least one hour per day indicates pBDD (Phillips, 2005), and less than one hour was used to indicate sBDD (Schneider et al., 2017).

The Body Image Questionnaire–Child and Adolescent Version (BIQ-C; Veale, 2009) assesses BDD symptom severity. The questionnaire begins with a screening item to determine if the participant has any appearance concerns. If participants do not report any concerns, they are given a total score of 0 and do not answer further items. Those with appearance concerns rank up to five body areas from most to least concerning, then answer 12 questions assessing appearance checking, distress, avoidance, and impairment. These items have tailored responses on a 0–8 scale, and after reverse-scoring three items, higher scores indicate greater symptom severity.

Although the original BIQ-C has 12 symptoms items, a recent study conducted in our larger adolescent sample supported using an alternate nine-item, two-factor version of the measure (the BIQ-C-9; Schneider et al., 2016a). This version had good internal consistency for male/female indi- viduals (total scale Cronbach’s α = .84/.89, interference and avoidance factor α = .71/.78, and other symptoms factor α = .76/.84). Among BDD participants in the current study, total scale internal consistency for male/female individuals was α = .79/.76. However, internal consistency in the two factors were relatively low (interference and avoidance α = .69/.65, other symptoms α = .65/.57). For this reason, only the BIQ-C-9 total score was utilized in the current study.

The body areas of concern reported in the BDDQ-A and BIQ-C-9 were coded based on body areas reported by Phillips (2005). If the participant reported being concerned about small body build, overall muscularity, or the muscu- larity of a specific body area (e.g., arm muscles), the response was coded as “muscle dysmorphia.” If they had other or unspecified body build concerns, this was coded as “body build.” If the concern was about overall excess weight or weight-related concerns about a specific area (e.g., fat legs), the response was coded as “weight.” If the participant did not specify what was disliked about the body area or it was not clearly related to weight or muscularity, it was coded as the specific body area (e.g., nose).

The child version of the 26-item Eating Attitudes Test (Maloney, McGuire, & Daniels, 1988) was used to measure disordered eating attitudes and behaviors. The least proble- matic responses (never, rarely, sometimes) are scored 0, and the remaining responses scored as 1 (often), 2 (very often), or 3 (always). Good internal consistency has been found in

adolescent populations (α = .86–.87; Rojo-Moreno et al., 2011; Smolak & Levine, 1994), and a total score of 20 or higher indicates a high probability of clinically significant eating disorder pathology (Maloney et al., 1988). In the current study, total scale Cronbach’s alpha values for male/ female participants were α = .78/.85.

The Spence Children’s Anxiety Scale (Spence, 1998) con- tains 38 items assessing social anxiety, separation anxiety, generalized anxiety, panic-agoraphobia, obsessive-compulsive disorder, and specific phobias (limited to physical injury- related fears). Items are scored 0 (never) to 3 (always). The scale has good psychometric properties, with support found for the six-factor model, acceptable internal consis- tency (total scale α = .92, subscale α = .60–.80), conver- gent and divergent validity, and test–retest reliability (Spence, Barrett, & Turner, 2003). Age and sex-specific cutoff scores have been developed from Australian com- munity norms; a T score of 60 indicates those in the top 15.9% of scores and is used to indicate elevated anxiety (Spence, n.d.). In the current study, Cronbach’s alpha values for the total scale for male/female participants were α = .92/.89, social anxiety α = .76/.60, separation anxiety α = .77/.46, generalized anxiety α = .78/.79, panic- agoraphobia α = .83/.85, obsessive-compulsive disorder α = .78/.74, and specific phobias α = .57/.51.

The Short Mood and Feelings Questionnaire (Angold, Costello, Messer, & Pickles, 1995) assesses depression symp- toms over the past 2 weeks. The 13 items are scored from 0 (not true) to 2 (true). The Short Mood and Feelings Questionnaire correlates well with diagnostic measures of depression and dis- criminates between depressed and nondepressed individuals, with a total score greater than 7 suggesting elevated depressive symptoms (Angold et al., 1995). It has strong internal consis- tency (α = .84–90; Angold, Erkanli, Silberg, Eaves, & Costello, 2002; Rhew et al., 2010). In this study, internal consistency for male/female participants was α = .90/.86.

Participants were asked to complete a small number of questions assessing demographics and whether they had ever received assessment or treatment for any mental health concerns. If so, they were asked to specify what types of professionals were seen and to briefly describe the reasons for seeking treatment. A school-level variable, the index of socioeducational advantage (ICSEA; Australian Curriculum and Assessment Reporting Authority, 2013), was used to estimate the socioeducational advantage of each school.

Male Participants Only

The Drive for Muscularity Scale (McCreary & Sasse, 2000) is a 15-item measure of muscularity-oriented behaviors and body image concerns. Items are scored from 1 (never) to 6 (always), and subscales are calculated as the mean of the items. As suggested by the authors of the measure, the item assessing anabolic steroid use was omitted, as it was unlikely to

SEX DIFFERENCES IN ADOLESCENT BDD 519

be relevant to this sample (McCreary, 2007). Good internal consistency has been reported in previous population-based studies of male adolescents and young adults (α = .85–.87; Brunet, Sabiston, Dorsch, & McCreary, 2010; McCreary, Sasse, Saucier, & Dorsch, 2004). For male participants in the current study, Cronbach’s alpha for the total scale was .90, muscularity-driven body image α = .91, and muscularity-driven behaviors α = 91.

Quality of life was assessed using the Pediatric Quality of Life Enjoyment and Satisfaction Questionnaire (Endicott, Nee, Yang, & Wohlberg, 2006). Life satisfaction is assessed using 14 items covering a range of physical, emotional, and social domains. A final item assessing total life satisfaction is not included in the total score. Items are scored from 1 (very poor) to 5 (very good), and the total score (range = 14–70) is converted to the percentage of the maximum possible score (range = 0–100%). The measure has good internal consistency (α = .87–.89) and test–retest reliability and provides unique information over and above measures of illness severity (Endicott et al., 2006; Merry et al., 2012). For male participants in this study, Cronbach’s α = .91.

The Strengths and Difficulties Questionnaire (Goodman, 1997) assesses emotional symptoms, conduct problems, hyper- activity, and peer problems using 20 items scored from 0 (not true) to 2 (certainly true), summed to form a total difficulties score. Age and sex-specific cutoff scores have been developed from Australian community norms that identify the top 10% of responses (Mellor, 2005). In the current study, male internal consistency for the total score α = .80, emotional symptoms α = .64, conduct problems α = .68, hyperactivity α = .72, and peer problems α = .67.

Data Analysis

Sex differences in the dependent variables were analyzed using chi-square tests with odds ratios (ORs) or Cramer’s V effect sizes for categorical variables, or independent samples t tests with Cohen’s d effect sizes for continuous variables. If a significant bivariate sex difference was found in a dependent variable, follow-up analyses were conducted to control for the effect of demographic vari- ables that varied by sex. These analyses were either logistic regressions with OR effect size for categorical variables, or analysis of covariance with partial eta- squared effect size for continuous variables. The Holm- Bonferroni sequential correction was applied to control the familywise error rate (α = .05) across each set of analyses.

RESULTS

Demographic Characteristics

Table 1 presents comparisons of demographic variables by sex. There were no significant sex differences in the

percentage of participants classified as pBDD compared to sBDD, parent occupation, family setting, or the per- centage of participants who spoke English as the main language at home. However, male participants were sig- nificantly older than female participants, and the socio- educational advantage of their schools was lower. Cultural background coding was condensed due to low numbers in some categories. Asian, African, American, and Middle Eastern backgrounds were coded as “other” and compared to Oceanian backgrounds (e.g., Australian, New Zealander, Melanesian, or Polynesian) or European backgrounds. There was a significant association between sex and parental cultural background, namely, male parti- cipants were more likely to report that their mothers and fathers had a European background, whereas female par- ticipants were more likely to report “other” backgrounds, most commonly, Asian backgrounds.

Body Dysmorphic Symptom Comparisons

Endorsement of BDDQ-A distress and interference criteria were compared between male and female participants. Endorsement of distress related to BDD did not vary sig- nificantly between male (65/93 = 69.9%) and female (48/ 69 = 69.6%) participants (χ2 = 0.00, p = .964, OR = 1.02), 95% confidence interval (CI) [0.52, 2.00]. Endorsement of BDD-related avoidance also did not vary significantly between male (57/93 = 61.3%) and female (39/ 69 = 56.5%) participants (χ2 = 0.37, p = .541, OR = 1.22), 95% CI [0.65, 2.29]. Interference with socializing or dating due to BDD was endorsed more frequently by male partici- pants (53/93 = 57.0%) than female (23/69 = 33.3%; χ2 = 8.90, p = .003, OR = 2.65), 95% CI [1.39, 5.06]; however, this bivariate relationship was not significant in a secondary logistic regression controlling for age, socioedu- cational advantage, and parent cultural background (main effect of sex, p = .210, OR = 2.14), 95% CI [0.65, 7.03]. Interference with school or work due to BDD was reported somewhat more frequently by male participants (22/ 93 = 23.7%) than female (7/69 = 10.1%), but this relation- ship was not significant after correction for multiple com- parisons (χ2 = 0.37, p = .044, OR = 1.22), 95% CI [0.65, 2.29].

Descriptive statistics for the BIQ-C-9 item and total scores are presented in Table 2. After correction for multiple comparisons, there were no significant sex differences in BIQ-C-9 items or the total score.

Body Areas of Concern

Female participants reported a larger number of different body areas of concern (M = 5.7, SD = 2.9) than male participants (M = 4.2, SD = 1.9), t(109.24) = 3.62, p < .001, d = 0.59, 95% CI [0.29, 0.93]; however, this difference was no longer significant in an analysis of

520 SCHNEIDER ET AL.

TABLE 1 Demographic Comparisons Between Male (n = 93) and Female (n = 69) Participants

Male Female Group Comparison

Categorical Variables n Valid % n Valid % χ2 p V

% pBDD 35 37.6 20 29.0 1.32 .205 .09 Speak English at home 77 92.8 33 84.6 1.99 .158 .13 Mother Cultural background 11.39 .003 .28 Oceanian 23 28.0 15 24.2 European 46 56.1 22 35.5 +

Othera 13 15.9 25 40.3 +

Father Cultural Background 13.57 .001 .31 Oceanian 22 29.3 22 33.8 European 47 62.7 24 36.9 +

Otherb 6 8.0 19 29.2 +

Mother Occupation 5.59 .235 .22 Not in the workforce 12 15.8 8 20.5 Manager/skilled professional 47 61.8 19 48.7 Trade/manual 0 0.0 2 5.1 Sales/clerical 9 11.8 4 10.3 Community/health 8 10.5 6 15.4

Father Occupation 4.38 .357 .20 Not in the workforce 4 5.5 3 7.9 Manager/skilled professional 42 57.5 23 60.5 Trade/manual 15 20.5 3 7.9 Sales/clerical 7 9.6 7 18.4 Community/health 5 6.8 2 5.3

Household Type 2.83 .243 .15 Two parent household 58 69.9 32 82.1 Single parent household 9 10.8 4 10.3 Step/Blended/Other household 16 19.3 3 7.7

Continuous Variables M SD M SD t p d

Age 15.1 1.3 14.5 1.3 2.97 .003 0.47 ICSEA 1046.3 40.0 1162.1 48.5 16.15 <.001 2.64

Note. Bold text indicates a significant sex difference after Holm-Bonferroni adjustment for multiple comparisons. + Adjusted residual > | 1.96|. BDD = Body dysmorphic disorder. ICSEA = Index of Community Socio-educational advantage. CI = Confidence interval. d = Cohen’s d. V = Cramer’s V.

aOther mother cultural background for males/females: North African and Middle Eastern (3.7/0.0%), Asian (7.3/30.6%), People of the Americas (2.4/8.1%), Sub-Saharan African (2.4/1.6%).

bOther father cultural background for males/females: North African and Middle Eastern (2.7/3.1%), Asian (4.0/23.1%), People of the Americas (1.3/1.5%), Sub-Saharan African (0.0/1.5%).

TABLE 2 BIQ-C-9 Item and Total Score Comparisons Between Male (n = 93) and Female (n = 69) Participants

Male Female t-Test Analyses

Item (Original Scale Numbering) M SD M SD t p d [95% CI]

3. Frequency of Checking Appearance 3.8 2.1 3.8 2.2 0.06 .950 0.01 [−0.32, 0.34] 4. Feeling That Feature Is Ugly/Not Right 4.3 1.8 4.2 1.9 0.29 .772 0.05 [−0.28, 0.38] 5. Amount of Distress 3.7 1.7 4.0 1.9 −0.86 .393 −0.14 [−0.47, 0.19] 6. Related Avoidance of Places or Activities 2.7 2.0 2.5 2.1 0.53 .601 0.09 [−0.24, 0.42] 7. How Much Feature Is on the Mind 4.8 1.7 4.5 1.7 1.26 .208 0.21 [−0.12, 0.54] 8. Effect on Romantic Relationships 3.9 2.3 3.7 2.6 0.35 .729 0.06 [−0.27, 0.39] 10. Interference With School Work 1.3 1.6 0.9 1.3 1.38 .170 0.23 [−0.10, 0.56] 11. Interference With Social Life 3.3 2.1 2.6 2.1 1.99 .049 0.34 [0.00, 0.67] 12. Appearance as Most Important Characteristic 4.2 1.9 3.9 1.8 1.65 .101 0.19 [−0.15, 0.52] Nine-Item Total Score 30.6 12.4 28.1 12.3 1.20 .232 0.20 [−0.13, 0.52]

Note: There were no significant analyses after Holm-Bonferroni correction for multiple comparisons. BIQ-C-9 = Body Image Questionnaire–Child and Adolescent Version, nine items; d = Cohen’s d; CI = confidence interval.

SEX DIFFERENCES IN ADOLESCENT BDD 521

covariance controlling for age, ICSEA, and parent cultural background (main effect of sex, p = .094, η2p= .022). Prior studies have found that male and female individuals differ in the nature of their concerns about hair, for example, thin- ning hair, excess hair, or hair style. In the current study, however, there was insufficient data to confidently code all responses according to the type of hair concern. Hence, a single hair concern variable was used. Table 3 shows sex differences in the body areas of concern that were endorsed by at least 10% of male or female participants. Significant bivariate sex differences were observed for seven of 20 body areas analyzed. Sex differences in concerns about muscularity, breasts/nipples, and thighs remained significant in logistic regressions controlling for age, ICSEA, and par- ent cultural background, whereas differences in concern about chest, stomach, eyes, and teeth were no longer significant.

Comorbid Symptom Severity

The percentage of participants with elevated levels of anxi- ety, depression and eating disorders, by sex, is shown in Table 4. The only significant sex difference was that female participants were more likely to report elevated generalized anxiety symptoms than male participants.

Past Mental Health Service use

Information about past mental health service use was provided by 131 participants (80.9%). Past mental health service use was more common in male (33/93 = 35.5%) than in female (5/ 38 = 13.2%) participants (χ2 = 6.53, p = .011, OR = 3.63), 95% CI [1.29, 10.19]. However, this effect was no longer significant in the follow-up logistic regression analysis (main effect of sex, p = .595, OR = 1.51), 95% CI [0.33, 6.87].

Of the 33 male and five female participants who had accessed mental health services, the most common profes- sionals consulted were school counsellors (male n = 20, female n = 3), psychologists (male n = 15, female n = 1), and psychiatrists (male n = 4, female n = 1). Information about the reasons for service use was disclosed by 26 male and five female participants, the most common of these being depres- sion/sadness (male n = 10, female n = 1), anxiety (male n = 6, female n = 2), and family problems (male n = 5, female n = 1). No participant reported BDD or appearance concerns as a reason for seeking mental health services.

Comparison of Male Participants With and Without Muscle Dysmorphia

Of the 93 male participants with pBDD or sBDD, 41 (44.1%) reported at least one body area of concern related

TABLE 3 Body Areas of Concern Comparisons Between Male (n = 93) and Female (n = 69) Participants

Male Female Chi-Square Bivariate Analysis Logistic Regressiona

Area n % n % χ2 p OR [95% CI] p OR [95% CI]

Skin 57 61.3 48 69.6 1.19 .275 1.44 [0.75, 2.80] — — Hair 33 35.5 25 36.2 0.01 .922 1.03 [0.54, 1.98] — — Nose 24 25.8 26 37.7 2.62 .106 1.74 [0.89, 3.41] — — Muscularity 41 44.1 3 4.3 31.62 < .001 17.35 [5.08, 59.19] < .001 24.28 [4.26, 138.31] Stomach 10 10.8 28 40.6 19.63 < .001 5.67 [2.51, 12.78] .77 3.71 [0.87, 15.83] Breasts/Nipples 1 1.1 31 44.9 48.06 < .001 75.05 [9.89, 569.67] < .001 121.44 [9.65, 1528.59] Legs 18 19.4 13 18.8 0.01 .934 1.03 [0.47, 2.28] — — Face—Other 14 15.1 13 18.8 0.41 .522 1.31 [0.57, 3.00] — — Height 14 15.1 13 18.8 0.41 .522 1.31 [0.57, 3.00] — — Weight 12 12.9 15 21.7 2.23 .136 1.88 [0.82, 4.32] — — Thighs 1 1.1 22 31.9 30.86 < .001 43.06 [5.63, 329.40] .005 31.68 [2.84, 353.54] Lips/Mouth 8 8.6 13 18.8 3.68 .055 2.47 [0.96, 6.33] — — Chest 19 20.4 1 1.4 13.19 < .001 17.46 [2.28, 133.96] .018 28.48 [1.80, 451.77] Arms 13 14.0 6 8.7 1.07 .301 1.71 [0.61, 4.74] — — Eyes 4 4.3 12 17.4 7.63 .006 4.68 [1.44, 15.24] .567 1.99 [0.19, 20.72] Body Build 11 11.8 4 5.8 1.72 .190 2.17 [0.66, 7.16] — — Teeth 4 4.3 10 14.5 5.21 .022 3.77 [1.13, 12.59] — — Hips 0 0.0 11 15.9 15.91 < .001 Hands 3 3.2 7 10.1 3.27 .070 3.39 [0.84, 13.61] — — Eyebrows 2 2.2 8 11.6 6.10 .014 5.967 [1.23, 29.06] — —

Note: Bold text indicates a significant sex difference after Holm-Bonferroni adjustment for multiple comparisons. Cells with dashes indicate that the value was not calculated as the bivariate relationship was not significant. The empty cells for hips indicate that the value could not be estimated, as the value of the outcome variable was 0 for all cases in a group for one or more predictor variables. OR = odds ratio, presented relative to the category with the lowest frequency; CI = confidence interval.

aLogistic regressions controlling for participant age, school socioeducational advantage, and parent cultural background.

522 SCHNEIDER ET AL.

to muscularity or small body build. Supporting the concep- tualization of muscle dysmorphia as a primarily male pre- sentation, such concerns were reported by just 4.3% of female participants. Table 5 compares male participants with and without muscularity concerns on a range of study variables. As predicted, male participants with muscularity concerns reported significantly higher muscularity-related body image scores on the Drive for Muscularity Scale, and a greater number of different body areas of concern, than those who did not report these concerns. However, there was no difference in quality of life or muscularity- related behaviors. There were no significant differences between groups with respect to BDD symptom severity, endorsement of BDD criteria, or rates of elevated comorbid symptoms, or with respect to past mental health service use; with muscle dysmorphia (13/41 = 31.7%) without muscle dysmorphia (20/52 = 38.5%), χ2(1, N = 93) = 0.46, p = .499, OR = 1.35, 95% CI [0.57, 3.19]. There were no differences between groups on any of the demographic variables assessed (details available from the corresponding author), so supplementary analyses were not required.

DISCUSSION

Although information about the presentation of adolescent BDD is vital for the early detection of the disorder, few studies have examined the presentation of BDD symptoms in adolescents, and there is little known about potential sex differences. The current study found that in adolescents with pBDD or sBDD recruited from the general community, there were few sex differences in the presenting features of BDD. Male and female participants were similar in the types of BDD symptoms endorsed; the association with

elevated depression, anxiety, and eating disorder symptoms; many body areas of concern; and rates of past mental health service use. However, there were sex differences in some body areas of concern, and female participants were more likely than male participants to report elevated symptoms of generalized anxiety disorder. Despite findings that muscle dysmorphia is associated with greater severity in adult male participants (Pope et al., 2005), muscle dysmorphia was not associated with a more severe BDD presentation in the present study.

Summary of Main Findings

Overall, there were few sex differences in the presentation of BDD, or in associated features. Contrary to hypotheses, female participants did not report higher levels of BDD- related appearance checking. Although male participants did report greater levels of social interference related to BDD, this was not significant after correcting for multiple compar- isons. There were no sex differences in endorsement of specific BDD symptoms, or in the overall severity of BDD symptoms. This is broadly consistent with adult studies, which have found few sex differences in the core symptoms of BDD (Perugi et al., 1997; Phillips & Diaz, 1997; Phillips et al., 2006).

As reported in clinical samples of adolescents (Albertini & Phillips, 1999; Phillips et al., 2006) and adults (Phillips, Menard, Fay, & Weisberg, 2005), the most common body areas of concern in the current study sample were skin, hair, and facial features. There was mixed support for the hypothesized sex differences in the body areas of concern. As predicted, male participants were significantly more likely to report muscularity concerns than female partici- pants, and female participants were more likely to report

TABLE 4 Comparison of Percentage of Participants With Elevated or High-Risk Comorbid Symptoms Between Male (n = 93) and Female (n = 69)

Participants

Male Female Chi-Square Bivariate Analysis Logistic Regressiona

Symptom Measure n % n % χ2 p OR [95% CI] p OR [95% CI]

Depression 57 61.3 49 71.0 1.66 .198 1.55 [0.79, 3.01] — — Total Anxiety 38 40.9 31 44.9 0.27 .605 1.18 [0.63, 2.22] — — Panic/Agoraphobia 36 38.7 28 40.6 0.06 .810 1.08 [0.57, 2.04] — — Separation Anxiety 29 31.2 17 24.6 0.84 .361 1.38 [0.69, 2.80] — — Social Anxiety 56 60.2 39 56.5 0.22 .637 1.16 [0.62, 2.19] — — Specific Phobia (Physical Injury) 40 43.0 19 27.5 4.10 .043 1.98 [1.02, 3.88] — — Obsessive-Compulsive Disorder 35 37.6 21 30.4 0.91 .341 1.37 [0.71, 2.68] — — Generalized Anxiety 34 36.6 42 60.9 9.40 .003 2.70 [1.42. 5.13] .032 3.75 [1.12, 12.58] Eating Disorder 4 5.1 6 9.4 0.97 .325 1.91 [0.52, 7.1] — —

Note: Bold text indicates a significant sex difference after Holm-Bonferroni adjustment for multiple comparisons. Cells with dashes indicate that the value was not calculated as bivariate relationship was not significant. OR = odds ratio, presented relative to the category with the lowest frequency; CI = confidence interval.

aLogistic regression controlling for participant age, school socioeducational advantage, and parent cultural background.

SEX DIFFERENCES IN ADOLESCENT BDD 523

concerns about breasts/nipples and thighs than male partici- pants. However, other hypothesized sex differences were not significant, or could not be properly assessed due to the coding system or low numbers for some comparisons.

Female participants were significantly more likely than male participants to report elevated symptoms of general- ized anxiety disorder, though other symptoms comparisons did not differ by sex. Elevated comorbid symptoms were common in male and female participants, particularly depression, social anxiety, and generalized anxiety. They occurred at a higher rate than is expected in the general adolescent population (Schmeelk-Cone, Pisani, Petrova, & Wyman, 2012; Spence, n.d.), which is consistent with the high comorbidity of these disorders with BDD in clinical samples (Albertini & Phillips, 1999; Mataix-Cols et al., 2015; Phillips et al., 2006). Elevated levels of eating dis- order pathology were less common in the current study, and comorbidity with eating disorders is relatively low in ado- lescents with BDD in clinical samples (0.0%–16.7%; Albertini & Phillips, 1999; Greenberg et al., 2016; Mataix-

Cols et al., 2015; Phillips et al., 2006). However, these studies are likely to have underestimated eating disorder comorbidity as they typically only assessed anorexia ner- vosa and bulimia nervosa, which may be less common in those with BDD compared to binge eating disorder and “not otherwise specified” eating disorders (Phillips et al., 2006).

Unexpectedly, past mental health service use was more common in male (35.1%) than in female (13.2%) partici- pants, though this difference was not significant when demo- graphic variables were controlled for. Service use appears to be lower than in other disorders; data from a national survey of 6,310 Australian children and adolescents showed 57.1% of those with mild depression and 40.2% with mild anxiety accessed mental health services in the past 12 months alone (Lawrence et al., 2015). Further, none of the current study participants who had used mental health services reported that their appearance concerns were a reason for seeking these services. Although this latter finding should not be taken as a proxy for poor BDD disclosure as we do not know whether their BDD symptoms were present at the

TABLE 5 Comparisons of Outcomes Between Male Participants With (n = 41) and Without (n = 52) Muscle Dysmorphia

With Muscle Dysmorphia Without Muscle Dysmorphia

Continuous Variables M SD M SD t p d [95% CI]

BIQ-C-9 Item Total 31.9 9.1 29.3 15.0 0.94 .349 0.21 [−0.23, 0.64] Drive for Muscularity Total Score 3.6 1.0 3.0 1.1 2.62 .011 0.56 [0.13, 1.00] Drive for Muscularity Body Image 4.7 1.2 3.9 1.4 3.07 .003 0.66 [0.22, 1.10] Drive for Muscularity Behaviors 2.5 1.4 2.1 1.3 1.24 .218 0.27 [−0.16, 0.70] Quality of Life 59.1 18.2 61.3 20.4 −0.47 .640 0.11 [−0.58, 0.36] No. of Body Areas of Concern 5.1 1.5 3.6 1.9 4.28 < .001 0.88 [0.44, 1.30]

Categorical Variables n % n % χ2 p OR [95% CI]

BDDQ-A 3a. Distress 31 75.6 34 65.4 1.14 .286 1.64 [0.66, 4.09] BDDQ-A 3b. Interference With Socializing or Dating 18 43.9 35 67.3 5.12 .024 2.63 [1.13, 6.13] BDDQ-A 3c. Interference With School or Work 11 26.8 11 21.2 0.41 .523 1.37 [0.52, 3.57] BDDQ-A 3d. Avoidance due to BDD 25 61.0 32 61.5 0.00 .956 1.02 [0.44, 2.37] Elevated Depression 27 65.9 30 57.7 0.64 .422 1.41 [0.61, 3.30] Elevated Total Anxiety 18 43.9 20 38.5 0.28 .596 1.25 [0.55, 2.88] Elevated Panic/Agoraphobia 14 34.1 22 42.3 0.64 .422 1.41 [0.61, 3.30] Elevated Separation Anxiety 12 29.3 17 32.7 0.13 .723 1.17 [0.48, 2.85] Elevated Social Anxiety 26 63.4 30 57.7 0.31 .576 1.27 [0.55, 2.95] Elevated Physical Injury Fears 17 41.5 23 44.2 0.07 .789 1.12 [0.49, 2.56] Elevated Obsessive-Compulsive Disorder 15 36.6 20 38.5 0.03 .853 1.08 [0.46, 2.52] Elevated Generalized Anxiety 17 41.5 17 32.7 0.76 .383 1.45 [0.62, 3.41] Elevated Eating Disorder 1 2.6 3 7.7 1.05 .305 3.17 [0.32, 31.86] Elevated Total Difficulties 16 39.0 16 30.8 0.69 .405 1.44 [0.61, 3.41] Elevated Emotional Symptoms 19 43.6 21 40.4 0.33 .565 1.28 [0.56. 2.91] Elevated Peer Problems 16 39.0 18 34.6 0.19 .661 1.21 [0.52, 2.82] Elevated Conduct Problems 12 29.3 12 23.1 0.46 .498 1.38 [0.54, 3.50] Elevated Hyperactivity 12 29.3 9 17.3 1.88 .171 1.98 [0.74. 5.29]

Note: Bold text indicates a significant muscle dysmorphia group difference after Holm-Bonferroni adjustment for multiple comparisons. BIQ-C-9 = Body Image Questionnaire–Child and Adolescent Version, nine Items. d = Cohen’s d; CI = confidence interval; BIQ-C-9 = Body Image Questionnaire–Child and Adolescent Version, nine items; OR = odds ratio, presented relative to the category with the lowest frequency; BDDQ-A = Body Dysmorphic Disorder Questionnaire–Adolescent Version.

524 SCHNEIDER ET AL.

time of service use, it is consistent with reports that indivi- duals with BDD typically present for other concerns, such as mood or anxiety disorders (Veale et al., 2015). Of note, the majority of young people who had accessed services had done so via school counsellors, underscoring the importance of educating school personnel about BDD.

Finally, many (44.1%) male participants reported con- cerns relating to muscularity or small body build, indicative of the muscle dysmorphia subtype of BDD (American Psychiatric Association, 2013). As predicted, male partici- pants with muscle dysmorphia reported higher muscularity- related body image concern, and were concerned about a higher number of different body areas, than those without muscle dysmorphia. However, contrary to findings in adults (Pope et al., 2005), we found no difference in the quality of life of male participants with and without muscle dysmor- phia, nor in the severity of BDD and comorbid symptoms. However, it is important to note that suicidality, substance use, and exercise behaviors were not assessed in the current study, which may be important correlates of muscle dys- morphia (Pope et al., 2005). The similarity in most present- ing features of male participants with and without muscle dysmorphia provides support for the current conceptualiza- tion of muscle dysmorphia as a subtype of BDD.

Limitations and Future Directions

The study began prior to the release of the Fifth Edition of the DSM (DSM-5), which expanded BDD criteria to include repetitive behaviors or mental acts, and clarified exclusion criteria regarding eating disorders (American Psychiatric Association, 2013). Although adult prevalence estimates are similar when using DSM-IV and DSM-5 criteria (Schieber, Kollei, De Zwaan, & Martin, 2015), this is yet to be established in adolescent samples. The use of self- report screening questionnaires may result in false positives (Brohede, Wingren, Wijma, & Wijma, 2013), for example, if the appearance concerns are realistic or due to another disorder. The study primarily involved participants with sBDD, so it is unclear whether the lack of sex differences observed in this sample is representative of youth with more severe BDD presentations. The BDDQ-A item excluding individuals with primary weight concern is intended to preclude eating disorders being incorrectly labeled as BDD (Phillips, 2005). However, 42.3% of adult female partici- pants and 11.1% of adult male participants with BDD report a lifetime history of an eating disorder (Phillips et al., 2006), and weight concerns are common in adolescents with BDD (Albertini & Phillips, 1999; Phillips et al., 2006). This exclusion criterion may therefore result in the underestima- tion of BDD prevalence where weight concerns are the primary feature of concern, and underestimation of the comorbidity between eating disorders and BDD. Future studies should explore ways to combine self-report ques- tionnaire assessment of BDD and eating disorders to

overcome these limitations. These studies should also assess a wider range of clinically relevant outcomes, such as sui- cidality and substance use, as well as administering all measures to male and female individuals. As insight may be particularly poor in adolescents with BDD (Phillips et al., 2006), multi-informant methods should be considered when assessing BDD in adolescents.

The schools recruited were a convenience sample of seven single-sex schools. The schools varied in the type of governing body, level of socioeducational advantage, and parental cultural background. Although school socioeduca- tional advantage and parental cultural background were controlled for in follow-up analyses of significant bivariate relationships, it is unknown whether other school factors may influence BDD symptom presentation. Given that the presentation of BDD in adults may be affected by factors such as culture and sexual identity (Boroughs, Krawczyk, & Thompson, 2010), future studies should explore the poten- tial impact of a range of demographic variables on BDD and involve a wider and more representative range of partici- pants, including those from coeducational schools and lower socioeducational advantage backgrounds.

The BIQ-C-9 subscales of interference and avoidance and other symptoms, devised in our whole sample in a previous study (Schneider et al., 2016a), had poorer than anticipated internal consistency. Hence, the psychometric properties of the BIQ-C-9 subscales and those of alternative measures (e.g. Veale et al., 2014) should be evaluated in future research. Although male participants with and with- out muscle dysmorphia were similar across many measures, further research is needed to examine the criteria and con- ceptualization of muscle dysmorphia, particularly in relation to eating disorders (Phillipou, Blomeley, & Castle, 2015).

Implications for Research, Policy, and Practice

The study findings indicate that core BDD symptoms are highly similar in male and female adolescents with pBDD and sBDD recruited from a community setting. They were also very similar in male adolescents with and without mus- cle dysmorphia concerns. This is an encouraging finding, as it indicates that clinicians can be trained to recognize the same types of BDD symptoms regardless of sex or muscularity concerns. In the sample as a whole, distress and avoidance were the most highly endorsed criteria on the BDDQ-A, and for BIQ-C-9 symptoms, mean scores were highest for items relating to preoccupation about appearance, negative evalua- tion of features, and the importance of appearance for self- evaluation. The most common body areas of concern related to the skin and hair, though there were some sex differences in concern about other body areas.

Elevated symptoms of depression and anxiety were reported by a majority of participants, and female partici- pants were significantly more likely to report elevated gen- eralized anxiety disorder symptoms than male. Although

SEX DIFFERENCES IN ADOLESCENT BDD 525

comorbid anxiety and depression is frequently reported in clinical samples of adolescents with BDD (Albertini & Phillips, 1999; Mataix-Cols et al., 2015; Phillips et al., 2006), this study indicates that BDD is closely associated with anxiety and depression in a nonclinical sample as well. Mental health service use was relatively low in the current study, especially compared to reported service use rates in other adolescent disorders (Lawrence et al., 2015). This is consistent with the low rates of treatment seeking reported in adult BDD studies (Buhlmann, 2011; Marques et al., 2011a). Further research is needed to determine specific service use barriers in adolescent BDD and to understand why male individuals are underrepresented in specialist BDD settings (Albertini & Phillips, 1999; Mataix-Cols et al., 2015; Phillips et al., 2006).

The underdiagnosis of BDD in routine clinical practice is a serious concern, and the results of the current study indicate that school counsellors and psychologists may have a key role in improving BDD detection. However, the majority of adolescents with pBDD and sBDD in our sample had never accessed a mental health service. Improving the detection and early intervention for BDD will thus require a broader approach, whereby adolescents and their parents are educated about the nature of BDD symptoms and encouraged to seek appropriate mental health treatment. Efforts to combat the shame associated with BDD may be particularly valuable, as this is commonly reported as a reason for not disclosing BDD (Marques et al., 2011).

In conclusion, the presentation of BDD is similar between male and female adolescents in a community sample. This includes the types of BDD symptoms endorsed, many of the body areas of concern, and the close association with anxiety and depression. In male adolescents, muscle dysmorphia was not associated with greater BDD severity or poorer quality of life. Public education about BDD and improved detection of BDD by clinicians is greatly needed in order to improve early detection of this serious disorder.

ACKNOWLEDGMENTS

We thank the students and staff of each school, and Laura Clark (PhD), Keila Brockveld (PhD), and Danielle Einstein (PhD) from the Centre for Emotional Health, Department of Psychology, Macquarie University, Sydney, Australia, for their assistance with data collection.

Please contact the corresponding author for requests regarding access to data.

FUNDING

The research was supported by (a) Macquarie University Research Excellence Scholarship awarded to Sophie

Schneider; (b) Australian Research Council grants LP130100576, FT120100217; (c) beyondblue National Priority Driven Research funding; and (d) a Sponsored Research Project grant from Macquarie University and one participant school awarded to Jennifer Hudson. These fund- ing sources had no involvement in the study design, data collection, analysis or interpretation, and writing of the report. Schools were given a copy of the completed manu- script prior to submission to check that details of school involvement were accurately reported.

ORCID

Sophie C. Schneider http://orcid.org/0000-0002-1469- 7764 Jonathan Mond http://orcid.org/0000-0002-0410-091X Jennifer L. Hudson http://orcid.org/0000-0001-5778- 2670

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