1 We

799925 ANP ANZJP ArticlesMalcolm et al.
Key Review
Australian & New Zealand Journal of Psychiatry
The relationship between body 2018, Vol. 52(11) 1030–1049

https://doi.org/10.1177/0004867418799925
DOI: 10.1177/0004867418799925
dysmorphic disorder and obsessive- © The Royal Australian and

New Zealand College of Psychiatrists 2018
compulsive disorder: A systematic Article reuse guidelines:

sagepub.com/journals-permissions
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review of direct comparative studies
Amy Malcolm1, Izelle Labuschagne1 , David Castle2,3,

Gill Terrett1, Peter G Rendell1 and Susan L Rossell2,4
Abstract
Objective: Current nosology conceptualises body dysmorphic disorder as being related to obsessive-compulsive disor-
der, but the direct evidence to support this conceptualisation is mixed. In this systematic review, we aimed to provide an
integrated overview of research that has directly compared body dysmorphic disorder and obsessive-compulsive disorder.
Method: The PubMed database was searched for empirical studies which had directly compared body dysmorphic
disorder and obsessive-compulsive disorder groups across any subject matter. Of 379 records, 31 met inclusion criteria
and were reviewed.
Results: Evidence of similarities between body dysmorphic disorder and obsessive-compulsive disorder was identified
for broad illness features, including age of onset, illness course, symptom severity and level of functional impairment, as
well as high perfectionism and high fear of negative evaluation. However, insight was clearly worse in body dysmorphic
disorder than obsessive-compulsive disorder, and preliminary data also suggested unique visual processing features,
impaired facial affect recognition, increased social anxiety severity and overall greater social-affective dysregulation in
body dysmorphic disorder relative to obsessive-compulsive disorder.
Conclusion: Limitations included a restricted number of studies overall, an absence of studies comparing biological
parameters (e.g. neuroimaging), and the frequent inclusion of participants with comorbid body dysmorphic disorder and
obsessive-compulsive disorder. Risks of interpreting common features as indications of shared underlying mechanisms
are explored, and evidence of differences between the disorders are placed in the context of broader research findings.
Overall, this review suggests that the current nosological status of body dysmorphic disorder is somewhat tenuous and
requires further investigation, with particular focus on dimensional, biological and aetiological elements.
Keywords
Obsessive compulsive and related disorders, body dysmorphic disorder, obsessive-compulsive disorder, anxiety disorders,
body image disorders
1Cognition and Emotion Research Centre, School of Psychology,

The conceptualisation of body dysmorphic disorder (BDD) Australian Catholic University, Melbourne, VIC, Australia
is an area of increasing research interest, given the recent 2Department of Psychiatry, St Vincent’s Hospital Melbourne, Melbourne,
and controversial classification of BDD within the new VIC, Australia

3Department of Psychiatry, Faculty of Medicine, Dentistry and Health
chapter of Obsessive Compulsive and Related Disorders in
Sciences, The University of Melbourne, Melbourne, VIC, Australia
the fifth edition of the Diagnostic and Statistical Manual 4Centre for Mental Health, Swinburne University of Technology,
of Mental Disorders (DSM-5; American Psychiatric Melbourne, VIC, Australia
Association, 2013). BDD is defined by a distressing preoc-
cupation with a perceived defect in one’s appearance, and Corresponding author:
Amy Malcolm, Cognition and Emotion Research Centre, School of
performance of excessive or repetitive behaviours or mental Psychology, Australian Catholic University, Level 5 of the Daniel Mannix
acts in response to this preoccupation such as mirror check- Building, 115 Victoria Parade, Fitzroy, VIC 3065, Australia.
ing and gazing, disproportionate grooming, modification or Email: amy.malcolm@myacu.edu.au
Australian & New Zealand Journal of Psychiatry, 52(11)

Malcolm et al. 1031
camouflaging of appearance, and mentally comparing appear- Method

ance to that of others (American Psychiatric Association,
2013). Despite being relatively common (prevalence of 1.7– A systematic search of the literature was conducted
2.4% in population estimates; Buhlmann et al., 2010; Koran through the PubMed database, using the search terms:
et al., 2008; Schneider et al., 2017), BDD is often under-rec- (body dysmorphic disorder OR dysmorphophobia OR
ognised (Zimmerman and Mattia, 1998). As such, improving dysmorphobia OR muscle dysmorphia) AND (obsessive
our conceptualisation of the condition might assist in improv- compulsive disorder OR obsessive-compulsive disorder).
ing clinical awareness and treatment decision-making, and Publication dates were inclusive from inception to 29
enhance research developments in understanding underlying January 2018. In addition, hand searches through refer-
aetiology. ence lists of included articles and relevant review articles
The currently dominant conceptualisation of BDD as were conducted. Article selection and reporting was con-
related to obsessive-compulsive disorder (OCD) within an ducted according to the Preferred Reporting Items for
‘obsessive-compulsive spectrum’ formed the basis for the Systematic Reviews and Meta-Analyses (PRISMA) pro-
classification of BDD and OCD in DSM-5 (Hollander tocol (Moher et al., 2009). Eligible articles were required
et al., 2010). This classification decision was based on to meet the following criteria: (1) Report original empiri-
assertions of overlap between BDD and OCD in areas of cal research of direct comparisons between discrete BDD
symptom presentation, comorbidity patterns, illness course, and OCD groups, wherein all participants had a current,
familiality, neurobiology, biomarkers, temporal anteced- confirmed clinical diagnosis. Review articles, meta-anal-
ents, and responsiveness to serotonin reuptake inhibitors yses, case studies, editorials, and opinion or correspond-
(Hollander et al., 2008; Phillips et al., 2010). As such, it ence letters were excluded. Furthermore, studies of
was hoped that the classification of BDD alongside OCD in non-clinical participants, sub-clinical BDD and OCD, or
DSM-5 would improve clinical awareness and understand- unconfirmed BDD or OCD (e.g. self-reported only) were
ing of BDD in accordance with the ‘obsessive-compulsive excluded. (2) Written in English language and be pub-
spectrum’ conceptualisation of the condition (Phillips et al., lished in a peer-reviewed journal (or accepted for publi-
2010). cation/in-press, provided the accepted full-text manuscript
However, the classification of BDD as an Obsessive- was available). Article abstracts were screened for rele-
Compulsive and Related Disorder has attracted critical vance, with full-text inspection used to confirm
debate. In particular, the strength and legitimacy of evidence eligibility.
to indicate a meaningful relationship between BDD and
OCD has been questioned, as claims of similarity relied Results
heavily on indirect comparisons with only a handful of
direct comparative investigations having been published at
Study selection
the time (Castle and Phillips, 2006; Chosak et al., 2008). In The search strategy yielded 379 articles after removal of
addition, theoretical and empirical problems have been duplicates. After determining eligibility, 31 articles were
identified in the arguments used to support claims of relat- selected for inclusion in the review (see Figure 1). A sum-
edness between BDD and OCD (Abramowitz and Jacoby, mary of each included article’s sample characteristics,
2015; Castle and Phillips, 2006; Frias et al., 2015). Beyond key findings, and methodological strengths and weak-
these concerns, it has been highlighted that BDD has been nesses is presented in Table 1. As noted in Table 1, sev-
relatively understudied and that there is a lack of knowledge eral articles appear to have shared a participant sample,
regarding specific aetiological mechanisms of the disorder. but addressed different research questions. Specifically,
Since the publication of the DSM-5, there have been Didie et al. (2007) and Phillips et al. (2007) appear to
considerably more direct comparative investigations of have reported on the same participants, as did the three
BDD and OCD. These investigations not only contribute to publications of Reese et al. (2010, 2011a, 2011b) and six
nosological conceptions of BDD, but importantly help elu- articles by Toh et al. (2015a, 2015b, 2017a, 2017b, 2017c,
cidate both the core and transdiagnostic features of the dis- 2017d). Where the same information was repeatedly
order. Knowledge of such features is essential for advancing reported across articles with shared samples, only the
future research into aetiological illness mechanisms and first mentioning article was cited. After accounting for
potential treatment pathways (Cuthbert, 2014). As such, these duplicate participant groups, we estimate that the
this systematic review seeks to synthesise research which selected articles collectively encompass up to 795 unique
has directly compared BDD and OCD, with the goal of individuals with BDD and up to 1334 unique individuals
delineating unique and shared features of the disorders. with OCD. Several studies also included a third group of
This delineation is additionally essential for clarifying the individuals with comorbid BDD and OCD (referred to as
evidence which underpins the current classification of BDD-OCD hereafter). These comparisons are not
BDD as an Obsessive Compulsive Related Disorder in the reported here, as the results did not contribute to our aims
DSM-5. of identifying clear overlaps and differences between the

1032 ANZJP Articles
Figure 1. PRISMA flow diagram of systematic search and article screening.
independent diagnostic entities of BDD and OCD. In Clinical characteristics

addition, several studies included individuals with BDD-
OCD within BDD and OCD groups. We have noted these Sociodemographics. Of the 22 studies which reported com-
studies in the text, as this inclusion may obscure delinea- parisons in one or more sociodemographic areas including
tion of differences between BDD and OCD. marital status, employment status, educational attainment
In reporting the results, the data were synthesised into and estimated IQ, most found broad similarities between
subcategories under the headings of Clinical Characteristics, BDD and OCD, despite some mixed findings (Aardema
Phenomenology, and Cognitive Function in accordance et al., 2018; Buhlmann et al., 2002, 2004, 2008, 2015; Cler-
with the available evidence. In addition, we calculated and kin et al., 2014; Didie et al., 2007; Frare et al., 2004; Hanes,
reported Cohen’s d effect sizes for results of group com- 1998; Hübner et al., 2016; McKay et al., 1997; Neziroglu
parisons using reported means and standard deviations, et al., 2006; Phillips et al., 1998, 2007, 2012; Reese et al.,
where possible. 2010, 2011b; Toh et al., 2015a, 2017b, 2017e; Tükel et al.,

Malcolm et al. 1033
Table 1. Summary of study groups, key findings, and study strengths and weaknesses for the reviewed studies.
Authors n Groups Key findings Study strengths Study weaknesses
Aardema et al. 33 BDD Greater fear of self in repugnant OCD Subdivided OCD Unequal group
(2018) subgroup vs BDD, ED, Anx/Dep, HC group by symptom numbers, small
144 OCD and non-repugnant OCD subgroup. dimension. BDD group.
Greater fear of self in BDD and ED vs Additional clinical
54 ED
non-repugnant OCD, Anx/Dep and HC, comparison
27 Anx/Dep and in non-repugnant OCD and Anx/ groups.
Dep vs HC.
141 HC
Buhlmann et al. 19 BDD Greater perfectionism in BDD and Excluded BDD- Some BDD
(2008) OCD vs HC. No difference for BDD vs OCD. participants did
21 OCD OCD. not complete self-
BDD rated attractive faces as higher in ratings.
21 HC
attractiveness than did OCD or HC.
Self-ratings of attractiveness were lower
in BDD vs OCD and HC.
Buhlmann et al. 20 BDD Facial affect recognition accuracy was Use of well- Did not report
(2004) less accurate for BDD vs HC. No validated facial BDD-OCD
20 OCD difference for OCD vs BDD and HC. affect photographs. inclusion or
Greater misidentification of affect as exclusion.
20 HC
anger in BDD vs OCD and HC. No
differences for OCD vs HC.
No group differences in discrimination
of facial features.
Buhlmann et al. 35 BDD Lesser accuracy of interpreting social Excluded BDD- Forced choice
(2015) situations in BDD and SAD vs HC. No OCD. responses.
35 OCD difference in accuracy for BDD vs SAD Included SAD Findings are
and OCD. Greater accuracy in OCD group. restricted
35 SAD
vs SAD. other-referential
35 HC More severe social anxiety in BDD, contexts only.
SAD, and OCD vs HC, and in BDD and
SAD vs OCD. No difference between
BDD vs SAD. More severe social
anxiety in SAD vs OCD.
Buhlmann et al. 19 BDD Negative interpretations in body- Excluded BDD- No OCD-relevant

(2002) relevant and social-relevant scenarios OCD. scenarios.
20 OCD were more common in BDD vs OCD
and HC. No differences for OCD vs
22 HC
HC.
Negative interpretations in general
scenarios were more common in BDD
and OCD vs HC.
Clerkin et al. 30 BDD Stronger implicit association between Excluded BDD- Social
(2014) shame and ‘body’ in BDD vs OCD, SAD OCD. performance
30 OCD and HC. Use of implicit relevant stimuli
Stronger implicit association between measures. were very narrow.
29 SAD
shame and ‘obsessive thoughts’ in OCD
33 HC vs BDD, SAD and HC.
No group differences for implicit
association of shame with ‘social
performance’.
More severe social anxiety in BDD,
SAD and OCD vs HC, and in BDD and
SAD vs OCD. No difference between
BDD vs SAD. More severe social
(Continued)

1034 ANZJP Articles
Table 1. (Continued)
Didie et al. (2007) 45 BDD No difference in quality of life and Separated BDD- No HC group.
Note: Same functional impairment between BDD vs OCD.
sample as Phillips 210 OCD OCD. Both have poor quality of life and Large sample.
et al. (2007) severe functional impairment.
40 BDD-
OCD
Eisen et al. (2004) 85 BDD Insight poorer in BDD vs OCD. Large sample. Did not report
Greater symptom severity associated BDD-OCD
64 OCD with poorer insight in BDD. No similar inclusion or
relationship found for OCD. exclusion.
Frare et al. (2004) 34 BDD Earlier age of onset in BDD vs OCD. Separated BDD- Unequal group
Marriages, employment, educational OCD. numbers.
79 OCD attainment lower in BDD vs OCD.
No group differences in current suicidal
24 BDD-
ideation.
OCD
Hanes (1998) 14 BDD Performance on executive function Inclusion of SCZ Small sample.
tasks was worse in BDD and OCD vs group. Did not report
10 OCD HC. No differences between BDD vs BDD-OCD
OCD. Performance was worse in SCZ inclusion or
14 SCZ
vs BDD, OCD and HC. exclusion.
32 HC Performance of category fluency, motor No measures of
skill and memory function tasks did symptom severity.
not differ between BDD, OCD and
HC. Performance was worse in SCZ vs
BDD, OCD and HC.
Hübner et al. 32 BDD No group differences in ability to Included SAD Did not report
(2016) identify aesthetic manipulations. group. BDD-OCD
32 OCD More severe social anxiety in BDD, inclusion or
SAD and OCD vs HC, and in BDD and exclusion.
32 SAD
SAD vs OCD. No difference between Possibly subject to
32 HC BDD vs SAD. More severe social practice effects.
McKay et al. 23 BDD Increased overvalued ideation in BDD Included measures Did not report
(1997) vs OCD. of different anxiety BDD-OCD
22 OCD Less severe anxiety in BDD vs OCD. types. inclusion or
No differences between BDD vs OCD exclusion.
for depressive symptom severity.
No differences between BDD vs OCD
for state and trait anxiety.
Neziroglu et al. 50 BDD Emotional and sexual childhood abuse Excluded BDD- No HC group.
(2006) was reported more often by BDD vs OCD. Retrospective self-
50 OCD OCD. Large sample. report.
No difference between BDD vs OCD
for reports of physical childhood abuse.
Phillips et al. 50 BDD No difference in number of suicide Separated BDD- Data on illness
(1998) attempts between BDD vs OCD. OCD. course is
Greater lifetime suicidal ideation and Large sample. retrospective self-
disorder-motivated suicide attempts in report.
BDD vs OCD.
(Continued)

Malcolm et al. 1035
53 OCD No difference in employment, living

arrangements, educational attainment
33 BDD- between BDD vs OCD. Fewer
OCD marriages in BDD vs OCD.
No difference in functional impairment,
houseboundness and psychiatric
hospitalisations between BDD vs OCD.
Phillips et al. 68 BDD Insight poorer in BDD vs OCD. Large participant Did not report
(2012) Excellent or good insight found for numbers. BDD-OCD
211 OCD 14.7% of BDD vs 55.4% of OCD inclusion or
participants. exclusion.
Poor or absent insight found for 72.1% Unequal group
of BDD vs 15.7% of OCD participants. numbers.
Phillips et al. 45 BDD Insight poorer in BDD vs OCD. Separated BDD- Unequal group
(2007) No differences in age of illness onset, OCD. numbers.
Note: Same 210 OCD illness course and duration, and Large sample. Participants were
sample as Didie functional impairment between BDD vs all receiving
40 BDD-
et al. (2007) OCD. treatment; unclear
OCD
Greater suicidal ideation in BDD vs how scores might
OCD. differ in untreated
No group differences in number of populations.
suicide attempts.
Reese et al. (2010) 20 BDD No group differences in accuracy of Excluded current Did not test own-
Note: Same symmetry detection for faces or dot or past BDD- face symmetry
sample as Reese 20 OCD arrays between BDD vs OCD. OCD. detection.
et al. (2011a,
20 HC
2011b)
Reese et al. 20 BDD Insight poorer in BDD vs OCD. Excluded current Evidence of ceiling
(2011a) No group differences in probabilistic or past BDD- effects.
Note: Same 20 OCD reasoning (jumping to conclusions bias). OCD. Did not include a
sample as Reese No correlations between insight and psychotic disorder
20 HC
et al. (2010, probabilistic reasoning for BDD and comparison group.
2011b) OCD groups.
Reese et al. 20 BDD No group differences in ability to Excluded current Did not include a
(2011b) recall what words had been presented, or past BDD- psychotic disorder
Note: Same 20 OCD mentally visualised or never presented OCD. comparison group.
sample as Reese (reality monitoring ability).
20 HC
et al. (2010,
2011a)
Saxena et al. 11 BDD Greater severity of depressive and First comparative 7 of 11 BDD
(2001) anxious symptoms in BDD vs OCD at investigation participants had
96 OCD pre-treatment. of treatment BDD-OCD.
Significant improvement from baseline outcomes. Wide variation
for both BDD and OCD. Greater in administered
improvement in severity of depressive medications.
and anxious symptoms for BDD vs Unequal group
OCD. numbers.
Silverstein et al. 20 BDD Performance on Ebbinghaus illusion and Included SCZ Did not report
(2015) contour integration test did not differ group. BDD-OCD
20 OCD between BDD, OCD and HC. Worse inclusion or
performance by SCZ vs BDD, OCD and exclusion.
24 SCZ
HC. Evidence of ceiling
20 HC effects.
(Continued)

1036 ANZJP Articles
Toh et al. (2017e) 27 BDD Insight poorer in BDD and SCZ vs Included SCZ Inclusion of
OCD and HC. No difference between group. individuals with
19 OCD BDD and SCZ, or between OCD and BDD-OCD in
HC. BDD group.
20 SCZ
Delusional proneness greater in OCD
42 HC and SCZ vs HC. No difference between
BDD and HC. Greater delusional
proneness in SCZ vs BDD. No
difference between OCD and BDD, or
OCD and SCZ.
Toh et al. (2015a) 21 BDD Performance of neuropsychological Use of a Did not report
Note: Same battery was worse in BDD and OCD comprehensive BDD-OCD
sample as Toh 19 OCD vs HC. No difference between BDD vs neuropsychological inclusion or
et al. (2015b, OCD. battery. exclusion.
21 HC
2017a, 2017b,
2017c, 2017d)
Toh et al. (2015b) 21 BDD Facial affect recognition was less Integrated eye- Did not report
Note: Same accurate in BDD vs OCD and HC. No tracking paradigm. BDD-OCD
sample as Toh 19 OCD difference for OCD vs HC. Use of well- inclusion or
et al. (2015a, Greater misidentification of affect as validated facial exclusion.
21 HC
2017a, 2017b, anger in BDD vs OCD and HC. No affect photographs.
2017c, 2017d) differences for OCD vs HC.
Atypical eye-tracking characteristics in
BDD vs HC. No differences between
OCD vs HC and BDD.
More severe social anxiety in BDD and
OCD vs HC. No difference between
BDD vs OCD.
Toh et al. (2017a) 21 BDD Emotive Stroop interference effects Integrated eye- OCD-relevant
Note: Same found for BDD-negative words in tracking paradigm. Stroop stimuli
sample as Toh 19 OCD BDD vs HC. No emotive Stroop Novel disorder- narrow in
et al. (2015a, interferences effects in OCD vs HC. relevant Stroop content.
21 HC
2015b, 2017b, Mild eye-tracking anomalies in BDD task. Inclusion of
2017c, 2017d) and OCD vs HC. Included disorganised individuals with
scanning and avoidance of disorder- BDD-OCD in
relevant words. BDD group.
Toh et al. (2017b) 21 BDD BDD-OCD found in 33% of individuals Thorough Inclusion of
Note: Same with primary BDD, vs 0% of individuals assessment individuals with
sample as Toh 19 OCD with primary OCD. of personality BDD-OCD in
et al. (2015a, Insight poorer in BDD vs OCD. disorders. BDD group.
21 HC
2015b, 2017a, No difference between BDD vs OCD
2017c, 2017d) in average number of personality
disorders.
Toh et al. (2017c) 21 BDD Reduced inversion effect in BDD vs Examination of Inclusion of
Note: Same OCD and HC for Mooney faces and configural and individuals with
sample as Toh 19 OCD objects. No difference between OCD detailed visual BDD-OCD in
et al. (2015a, vs HC. processes. BDD group.
21 HC
2015b, 2017a, More accurate recognition of inverted Use of face and
2017b, 2017d) faces in BDD vs OCD and HC. No object stimuli.
difference between OCD vs HC.
(Continued)

Malcolm et al. 1037
Toh et al. (2017d) 21 BDD Less accurate recognition of own-face Integrated eye- Refusal to
Note: Same affect in BDD vs HC. No difference in tracking paradigm. participate in
sample as Toh 19 OCD OCD vs BDD and HC. own-face viewing
et al. (2015a, Less accurate recognition of neutral task by 33% BDD,
21 HC
2015b, 2017a, expressions on unfamiliar faces in OCD 10.5% OCD and
2017b, 2017c) vs HC. No difference in OCD vs BDD. 4.8% HC.
Greater eye-tracking anomalies during Inclusion of
own-face viewing in BDD vs OCD and individuals with
HC. BDD-OCD in
BDD group.
Tükel et al. 29 BDD No differences in depressive symptom Separated BDD- Unequal group
(2013) severity between BDD vs OCD. OCD. sizes.
49 OCD More severe anxiety symptoms in OCD
vs BDD.
20 BDD-
Narcissistic, histrionic and avoidant
OCD
personality disorders more common in
BDD vs OCD.
Veale et al. (2002) 100 BDD BDD were more likely than all other Large sample. Retrospective
groups to have an occupation or Included MDD and data from patient
100 OCD education in arts and design (20% BDD, PTSD groups. case records.
4% MDD, 4% OCD and 0% PTSD). No measures of
100 MDD
symptom severity.
100 PTSD
Yaryura-Tobias 10 BDD Five BDD, four OCD and no HC Novel Small sample.
et al. (2002) participants digitally manipulated a experimental Did not report
10 OCD photograph of their own faces to paradigm. BDD-OCD
correct perceived distortions. inclusion or
10 HC
No group differences across three exclusion.
Wechsler Adult Intelligence Scale-III Descriptive data
subtests of visual comprehension. not reported
for clinical
assessments.
n: number of participants per group; BDD: body dysmorphic disorder; OCD: obsessive-compulsive disorder; Anx/Dep: mixed anxiety and depressive
disorders; ED: eating disorders; HC: healthy control; BDD-OCD: comorbid BDD and OCD; SAD: social anxiety disorder; SCZ: schizophrenia;
MDD: major depressive disorder; PTSD: post-traumatic stress disorder.
2013; Veale et al., 2002). Findings of difference included and 21.2 years for OCD. While one of these studies reported
fewer marriages in BDD than in OCD in two of six studies a significantly earlier mean age of onset for BDD relative to
(Frare et al., 2004; Phillips et al., 1998). Mixed results were OCD (d = 0.52; Frare et al., 2004), the remaining five found
also reported in two of five comparisons of employment no significant differences in the mean age of illness onset
status (Frare et al., 2004; Toh et al., 2017e) and in two of 13 between the two disorders (d range = 0.06–0.40; Neziroglu
comparisons of educational attainment (Frare et al., 2004; et al., 2006; Phillips et al., 1998, 2007, 2012; Tükel et al.,
Tükel et al., 2013). In addition, one of four studies reported 2013). In addition, one study found no significant differences
a higher IQ in BDD relative to OCD (Toh et al., 2017e). in mean age of subclinical BDD and OCD symptom onset
Finally, one study found that significantly more BDD par- (d = 0.17), which was reported as 11.9 years (standard devia-
ticipants had an occupation or education in arts and design, tion [SD] = 8.2) in BDD and 13.1 years (SD = 5.2) in OCD
relative to OCD, major depression and post-traumatic stress (Phillips et al., 2007). Overall, these results demonstrate
disorder (PTSD) participants; this was interpreted as sig- strong similarity in the mean ages of BDD and OCD onset.
nalling BDD is associated with a predisposition towards
aesthetic occupations (Veale et al., 2002). Illness course. A retrospective study of illness course found
generally similar patterns between BDD and OCD partici-
Age of onset. Across six studies, the mean age of illness onset pants (free of BDD-OCD), with some exceptions (Phillips
ranged between 16 and 18.3 years for BDD and between 14 et al., 1998). Gradual illness onset was predominant in both

1038 ANZJP Articles
groups (76% BDD, 71% OCD), while acute onset was Overvalued Ideas Scale (McKay et al., 1997; Neziroglu
reported by approximately a quarter of each group. Both et al., 1999). Phillips et al. (2012) also demonstrated sig-
groups also largely exhibited a chronic, continuous illness nificant group differences in the distribution of insight
course (92% BDD, 96% OCD) rather than episodicity. scores, with the majority of BDD participants demonstrat-
However, individuals with BDD were significantly more ing poor or absent insight (72% BDD, 16% OCD), and the
likely than those with OCD to report their illness had wors- majority of OCD participants demonstrating good or excel-
ened with time (62% BDD, 36% OCD), while a signifi- lent insight (55% OCD, 15% BDD). Interestingly, Toh
cantly higher proportion of the OCD group reported a stable et al. (2017e) further found similar levels of insight among
illness course (16% BDD, 51% OCD). BDD participants and a schizophrenia/schizoaffective dis-
orders group (d = 0.24) and significantly better insight in
Treatment response. Only one study has reported on treat- OCD relative to the schizophrenia/schizoaffective group
ment response in BDD and OCD groups (Saxena et al., (d = 1.38).
2001). No significant differences were present in pre-treat-
ment illness severity (d = 0.38), but depressive and anxious Propensity for delusional thinking styles. Two studies found
symptoms were significantly more severe in the BDD no significant differences between BDD and OCD for pro-
group than in the OCD group (d = 0.98, 0.92). After a pensity to engage in broadly unusual thinking styles
6-week multimodal treatment intervention, both groups had (d range = 0.31–0.58; Silverstein et al., 2015; Toh et al.,
improved significantly across all baseline measures, with 2017e), as measured by the Peters Delusional Inventory
no significant group differences in post-treatment illness (Peters et al., 1999). Toh et al. (2017e) additionally found
severity (d = 0.20) and depressive and anxious symptom significantly higher scores for unusual thinking style in
severity (d = 0.13, 0.17). However, the findings of this study OCD relative to healthy controls (d = 1.40), with no differ-
may be more relevant to the treatment of OCD and BDD- ence between OCD participants and a schizophrenia/
OCD than BDD, as 7 of the 11 BDD participants had BDD- schizoaffective group (d = 0.40; Toh et al., 2017e). Con-
OCD. Furthermore, the BDD group (n = 11) was relatively versely, similar scores were found for BDD relative to con-
small compared to the OCD group (n = 96). trols (d = 0.68), with BDD demonstrating significantly
lower scores than the schizophrenia/schizoaffective group
Primary symptom severity. Across eight studies which com- (d = 0.94). These results suggest BDD and OCD may have
pared BDD and OCD symptom severity using disorder- similar, yet differently graded positions on a continuum of
specific measures, none reported significant between-group propensity for unusual thinking styles.
differences (d range = 0.01–0.05), with qualitative inspec-
tion revealing mean scores in the moderate-to-severe range Depressive symptoms. Depressive symptoms appear to be
for both groups across all studies (Didie et al., 2007; Eisen broadly comparable across BDD and OCD, as 10 of 14
et al., 2004; Frare et al., 2004; Phillips et al., 1998, 2007, studies reported no significant differences in depressive
2012; Toh et al., 2015a, 2017e). All studies used the analo- symptom severity between BDD and OCD groups
gous Yale Brown Obsessive Compulsive Scale (YBOCS) (d range = 0.20–0.50; d could not be calculated for one
for OCD participants and the YBOCS Modified for BDD study; Buhlmann et al., 2015; Clerkin et al., 2014; Hanes,
(BDD-YBOCS) for BDD participants. Severity scores on 1998; Hübner et al., 2016; McKay et al., 1997; Phillips
the thought and behaviour subscales of the YBOCS and et al., 2007; Reese et al., 2011b; Toh et al., 2015b; Tükel
BDD-YBOCS were further examined in two studies, both et al., 2013; Yaryura-Tobias et al., 2002). However, the
of which found no difference between BDD and OCD in remaining four studies reported significantly more severe
the severity of symptomatic behaviours (d = 0.16, 0.19; depressive symptoms in BDD than in OCD, with large
Eisen et al., 2004; Phillips et al., 2012). However, Phillips effect sizes (d range = 0.92–1.16; Buhlmann et al., 2002,
et al. (2012) reported significantly greater severity of symp- 2004, 2008; Saxena et al., 2001); although it should be noted
tomatic thoughts in OCD than BDD (d = 0.50), while Eisen that one of these studies included seven BDD-OCD partici-
et al. (2004) found no group differences in this respect pants in the small BDD group (n = 11), which may have con-
(d = 0.21). tributed to findings of elevated depressive symptoms in the
BDD group (Saxena et al., 2001). Qualitative inspection of
Insight. All eight studies which examined illness insight group means reported by all 14 studies demonstrated that
found significantly poorer insight in BDD than in OCD, depressive symptoms were generally of mild-to-moderate
with very large effect sizes (d range = 1.45–3.86; Eisen clinical severity for both BDD and OCD groups.
et al., 2004; Phillips et al., 2007, 2012; Reese et al., 2011a;
Silverstein et al., 2015; Toh et al., 2017c, 2017e). All but Generalised anxiety symptoms. Mixed findings were reported
one of these studies used the well-validated Brown Assess- across the four studies which compared generalised anxiety
ment of Beliefs Scale (BABS; Eisen et al., 1998) to mea- symptoms. The largest of the four studies reported no signifi-
sure insight, with McKay et al. (1997) employing the cant differences between BDD and OCD for severity of

Malcolm et al. 1039
anxiety symptoms (d = 0.61; Tükel et al., 2013). Two smaller Functional impairment. The largest and most comprehensive
studies reported significantly more severe anxiety in OCD of five studies of functional impairment reported that both
than in BDD (d = 0.41, unable to calculate d for one study; BDD and OCD were associated with significant functional
McKay et al., 1997; Yaryura-Tobias et al., 2002). By con- impairment and poor quality of life across many domains,
trast, Saxena et al. (2001) reported significantly more severe including interpersonal, recreational, academic, occupational,
anxiety in BDD than in OCD (d = 0.98; although high rates of role functioning, and psychological and physical health
BDD-OCD in the BDD group may have influenced this find- (Didie et al., 2007). Similarly, the remaining four studies vari-
ing). Qualitative inspection of group means across all four ously demonstrated that both disorders encompass similarly
studies revealed that anxiety symptoms were in the mild-to- high rates of global functional impairment, psychiatric hospi-
severe ranges for both groups. In sum, the results might sup- talisations (e.g. 58% BDD, 51% OCD), being housebound
port somewhat elevated generalised anxiety symptoms in (e.g. 31% BDD, 32% OCD) and mental health disability sta-
OCD versus BDD but are inconclusive at present. tus (17.8% BDD, 15.7% OCD; Neziroglu et al., 2006; Phil-
Two investigations of fluctuating and dispositional anxi- lips et al., 1998, 2007; Saxena et al., 2001).
ety using the State-Trait Anxiety Inventory (Spielberger
et al., 1983) also demonstrated mixed results. The larger Suicidality. Data from four studies demonstrated mixed
study (n = 30 per group) of participants free of BDD-OCD findings regarding levels of suicidal ideation and history of
manifested significantly greater state (d = 0.68) and trait suicide attempts between BDD and OCD. Lifetime gener-
(d = 0.48) anxiety in BDD than in OCD (Clerkin et al., alised suicidal ideation (i.e. ideation not specifically linked
2014). However, the smaller study of McKay et al. (1997) to BDD/OCD symptoms) was more often reported by BDD
reported no BDD versus OCD differences in state (d = 0.39) than OCD participants in one study (78% BDD, 55% OCD;
or trait (d = 0.29) anxiety. Across both of these studies, Phillips et al., 2007). Conversely, a second study reported
symptom scores fell within moderate-to-severe severity no differences between BDD and OCD for severity of cur-
ranges for both groups. rent generalised suicidal ideation (27% BDD, 20% OCD;
Frare et al., 2004). Regarding suicidal ideation specifically
Social anxiety symptoms. Although mixed findings were linked to BDD and OCD symptoms, one study found that
reported across four studies of social anxiety severity, the significantly more BDD than OCD participants reported
overall data indicate greater severity of social anxiety suicidal ideation (70% BDD, 47% OCD; Phillips et al.,
symptoms in BDD than in OCD. Two of the four studies 1998), while another study found no group differences in
found significantly more severe social anxiety in BDD than this respect (62% BDD, 44% OCD; Phillips et al., 2007). In
in OCD, with medium-to-very large effect sizes (d = 0.57, terms of suicide attempts, two studies found no significant
1.08; Buhlmann et al., 2015; Clerkin et al., 2014), while the differences in the proportion of BDD (13–29%) and OCD
remaining two studies reported no significant differences (16–19%) participants who reported prior suicide attempts
between BDD and OCD groups (d = 0.24, 0.57; Hübner (Phillips et al., 1998, 2007). However, Phillips et al. (1998)
et al., 2016; Toh et al., 2015b). In all four studies, compari- reported that significantly more BDD (22%) than OCD
sons to controls demonstrated significantly greater social (8%) participants cited their disorder as the primary impe-
anxiety severity in both BDD (d range = 1.05–2.48) and tus for having attempted suicide.
OCD (d range = 0.81–1.37). However, further comparisons
to a primary social anxiety disorder (SAD) group in three of Comorbidities. Studies of comorbidity have found that BDD
these studies showed no significant differences between and OCD are similar in the overall number of comorbid
BDD and SAD (d range = 0.36–0.39; Buhlmann et al., psychiatric conditions. Toh et al. (2015a) reported no sig-
2015; Clerkin et al., 2014; Hübner et al., 2016). By con- nificant differences for the average number of any current
trast, social anxiety severity was significantly lessened in comorbid psychiatric disorder per participant between
OCD relative to the SAD group across all three of these BDD and OCD groups (BDD M = 2.8, SD = 1.6, OCD
studies (d range = 0.95–1.54). M = 1.7, SD = 1.1), nor for the average number of personal-
ity disorders per participant between BDD and OCD groups
Childhood maltreatment. A single study of 50 BDD and 50 (BDD M = 1.4, SD = 1.4, OCD M = 1.1, SD = 1.6). Simi-
OCD participants free of lifetime BDD-OCD found that larly, Neziroglu et al. (2006) reported no differences in the
those with BDD made significantly more reports of child- proportion of BDD and OCD patients who had at least one
hood sexual (22% vs 6%) and emotional (28% vs 2%) currently comorbid psychiatric disorder (78% BDD, 62%
abuse than OCD participants (Neziroglu et al., 2006). Con- OCD).
versely, similar proportions of both groups (14% BDD vs The prevalence of specific comorbid disorders within
8% OCD) reported childhood physical abuse. However, the BDD and OCD groups has been statistically examined
absence of a healthy control group in this study prevents across four studies, with mixed findings (Frare et al., 2004;
comparison of these abuse rates to those of a non-clinical Phillips et al., 1998, 2007; Tükel et al., 2013). The surveyed
population, thus rendering these findings inconclusive. disorders included major depressive disorder (MDD),

1040 ANZJP Articles
bipolar I and II, dysthymic disorder, SAD, panic disorder, OCD (d = 0.52). Interestingly, a mixed eating disorders
generalised anxiety disorder, specific phobia, anorexia ner- (ED) group demonstrated the same patterns as BDD; that
vosa (AN) or bulimia nervosa, alcohol or substance use dis- is the ED group and BDD did not significantly differ
order, and somatoform disorders. While results were (d = 0.15), and the ED group shared the same pattern of
generally mixed across these studies, a higher prevalence significant differences as BDD relative to both OCD sub-
of MDD in BDD than in OCD was found in two studies, as groups. Finally, fear of self was significantly greater in all
were higher rates of alcohol and substance use disorders clinical groups relative to healthy controls, with very large
(Frare et al., 2004; Phillips et al., 1998, 2007). One study effect sizes (d range = 1.01–2.1).
further reported higher rates of SAD and psychotic disor-
ders in BDD than in OCD, although the elevated rate of Facial attractiveness judgements. The only published study
psychotic disorders may be explained by the outmoded of facial attractiveness judgements found significant differ-
Diagnostic and Statistical Manual of Mental Disorders ences between BDD and OCD in ratings of attractive faces
(4th ed.; DSM-IV) method of double-coding delusional and in ratings of own attractiveness (Buhlmann et al.,
BDD as a psychotic disorder (Phillips et al., 1998). 2008). While BDD, OCD and control participants each
Generalised anxiety disorder was more common in OCD gave similar classifications of faces as ‘average’, ‘attrac-
than in BDD in one study (Frare et al., 2004), and conflict- tive’ or ‘unattractive’, BDD participants gave significantly
ing results were found across two studies for the prevalence higher ratings of attractiveness to the attractive faces than
of dysthymic disorder. However, the remaining compari- did OCD (d = 1.04) or control participants (d = 1.19). Fur-
sons variously demonstrated no significant differences thermore, BDD participants gave themselves significantly
between BDD and OCD across these disorders. In terms of lower ratings of attractiveness than did the OCD (d = 0.81)
comorbid personality disorders, Tükel et al. (2013) found a and control participants (d = 0.89), despite all three groups
significantly greater prevalence of narcissistic, histrionic placing themselves within an ‘average’ attractiveness
and avoidant personality disorders in BDD than in OCD. In range. In a subset of participants who allowed their image
addition, Tükel et al. (2013) further reported that individu- to be rated by independent evaluators (n = 13/19 BDD,
als with BDD were more likely than those with OCD to 16/21 OCD and 19/21 controls), only the BDD partici-
have a personality disorder, especially Cluster B personal- pants’ ratings were significantly lower than those of inde-
ity disorders. Phillips et al. (2007) reported a significantly pendent evaluators. Importantly, the independent evaluators
greater prevalence of paranoid personality disorder in BDD gave similar mean ratings to all three groups (d range = 0.00–
than in OCD, but no further differences. In sum, the avail- 0.07), which suggests BDD participants’ low self-ratings
able data regarding the prevalence of specific comorbidities were attributable to their own self biases rather than any
among BDD and OCD provide no conclusive evidence of objective unattractiveness.
similarity or difference in terms of comorbidity patterns
between the disorders. Perfectionism. A single study reported no significant differ-
Finally, results from one study indicate that there is a ences between BDD and OCD in overall perfectionism
higher rate of comorbid OCD within primary BDD, than scores (d = 0.11), with both groups demonstrating signifi-
vice versa. Toh et al. (2017b) found comorbid lifetime and cantly higher scores than controls (d = 0.92–0.96; Buhl-
current OCD in 33% and 23.8% of the primary BDD group, mann et al., 2008). In sub-dimensions of perfectionism,
respectively. Conversely, there was no incidence (0%) of both clinical groups demonstrated significantly higher
lifetime or current BDD in the OCD group. scores than controls for ‘doubting of actions’ (OCD
d = 2.19; BDD d = 1.15) and ‘concern over mistakes’
(d = 1.35 for both groups). While BDD and OCD did not
Phenomenology
differ in scores for ‘concern over mistakes’ (d = 0.03), the
Fear of self. A recent investigation of feared self-percep- OCD group scored significantly higher than the BDD group
tions using the Fear of Self Questionnaire (Aardema et al., for ‘doubting of actions’ (d = 0.88). No further group differ-
2013) demonstrated complex positioning of BDD relative ences were found across the remaining sub-dimensions of
to specific subtypes of OCD (Aardema et al., 2018). Initial ‘personal standards’, ‘parental expectations’, ‘parental crit-
assessment of OCD participants in this study found signifi- icism’ and ‘organisation’.
cantly greater fear of self in individuals with personally
repugnant obsessions (e.g. moral, sexual, religious, aggres- Shame. A single study investigated implicit associations of
sive) than in those with personally non-repugnant concerns shame with the body, intrusive thoughts, and public speak-
(e.g. contamination, checking, ordering and arranging, ing performance (Clerkin et al., 2014). The BDD group
somatic, or other, d = 1.05). Comparison of the repugnant demonstrated significantly stronger implicit associations of
and non-repugnant OCD subgroups to the BDD group shame with the body as compared to OCD, SAD and
revealed significantly greater fear of self in r epugnant-OCD healthy control participants. Moreover, the OCD group
versus BDD (d = 0.58), and in BDD versus non-repugnant demonstrated significantly stronger implicit associations of

Malcolm et al. 1041
shame with intrusive thoughts as compared to all other words (e.g., ‘ugly’) relative to healthy controls, while no dif-
groups. No group differences were found in the strength of ferences were observed between OCD and control partici-
implicit associations between shame and public speaking pants. Furthermore, eye-tracking analysis showed subtle
performance. anomalies in both clinical groups relative to controls, includ-
ing increased fixations in OCD and decreased visual atten-
Fear of negative evaluation. Of the three studies which com- tion in BDD for BDD-negative and OCD-washing words.
pared BDD and OCD using the Brief Fear of Negative Qualitative inspection additionally found disorganised view-
Evaluation scale (Carleton et al., 2006), two reported no ing strategies in both clinical groups, which included avoid-
significant differences between BDD and OCD groups ance of disorder-relevant words. Of note, the OCD-relevant
(d = 0.18, 0.70; Buhlmann et al., 2004; Toh et al., 2015a). stimuli in this study were restricted to washing and checking
The third found significantly higher fear of negative evalu- words, and therefore these stimuli may have been too narrow
ation scores in BDD relative to OCD, with a large effect to elicit attentional biases from all OCD participants, as not
size (d = 0.93; Buhlmann et al., 2002). However, all three all had washing or checking concerns.
studies found that both BDD and OCD demonstrated sig-
nificantly higher scores than healthy controls, with very Facial affect recognition. Despite some inconsistencies, data
large effect sizes (d range = 1.29–2.90). As such, fear of from three studies suggest fine-grained differences in facial
negative evaluation appears to be a prominent concern in affect recognition between BDD and OCD, particularly in
both disorders. relation to healthy controls (Buhlmann et al., 2004; Toh
et al., 2015b, 2017d). While Toh et al. (2015b) found sig-
Interpretive biases. One study found that BDD participants nificantly impaired affect recognition in BDD relative to
were significantly more likely than OCD and healthy con- OCD using unfamiliar faces (unable to calculate d for this
trol participants to interpret ambiguous social and body- study), no significant group differences were reported by
focused situations as being personally relevant and Buhlmann et al. (2004) for the same task (d = 0.41). How-
threatening (e.g. ‘Others are negatively judging my social ever, both studies reported significant impairment in BDD
performance/bodily appearance’; Buhlmann et al., 2002). relative to healthy controls (d = 0.95), with no differences
However, both the BDD and OCD groups made signifi- between OCD and control participants (d = 0.58). More-
cantly more negative interpretations of general situations over, both studies found that the BDD group misidentified
(not involving socialisation or body focus) than did healthy expressions as anger significantly more often than both the
controls, suggesting both clinical groups share a tendency OCD (d = 0.59) and control groups (d = 1.12). Using a sub-
to interpret ambiguous information as threatening (Buhl- set of the same participant sample as Toh et al. (2015b;
mann et al., 2002). n = 14/21 BDD, 17/19 OCD, 20/21 control participants),
Toh et al. (2017d) further found that accuracy of own-face
Cognitive function affect recognition was not significantly different between
BDD and OCD participants (d = 0.39). However, compari-
Social cognition. Results from a single study suggested that son to controls demonstrated significantly poorer affect
BDD and OCD overlap yet may subtly differ in social cog- recognition in BDD (d = 0.96), with no differences between
nitive functioning (Buhlmann et al., 2015). Using the OCD and control participants (d = 0.56).
Movie for the Assessment of Social Cognition, this study
found no significant differences between BDD and OCD Visual processing of faces. Mixed results were found across
for overall accuracy of social inferences (d = 0.55). How- four studies of facial visual processing, with some data sug-
ever, additional comparisons revealed similarly poor accu- gesting abnormal visual scan strategies in BDD relative to
racy of social inferences scores in BDD and a group with OCD. Toh et al. (2015b) found no significant differences
SAD (d = 0.37), such that both BDD and SAD had signifi- between BDD and OCD for visual scan strategies used dur-
cantly poorer scores than healthy controls, with large effect ing the viewing of unfamiliar faces. However, the BDD
sizes (d = 0.72 and 1.06, respectively). Conversely, no dif- group demonstrated significantly more disorganised scan
ference was found between OCD and healthy controls strategies than controls, while OCD and controls did not
(d = 0.14), with significantly greater accuracy scores in differ. Within a subset of the same sample, Toh et al.
OCD than in SAD (d = 0.89). (2017d) identified significantly greater anomalies in visual
scanning strategies during own-face viewing in BDD rela-
Attentional biases. A single study found no differences tive to both OCD and healthy controls. Conversely, OCD
between BDD and OCD in behavioural performance on a and controls did not differ. In addition, scan strategies of
disorder-relevant emotional Stroop task, or in eye-tracking BDD participants with facial preoccupations were qualita-
data for visual scan strategies used during task performance tively distinguishable by excess fixation, avoidance or
(Toh et al., 2017a). However, BDD participants demon- intermittent checking of preoccupying features (Toh et al.,
strated significant interference effects for BDD-negative 2017d).

1042 ANZJP Articles
Other research found no significant differences between and visual comprehension, but clearly indicate enhanced
BDD, OCD and healthy control participants on the Benton detailed visual processing in BDD versus OCD.
Facial Recognition Test (d range = 0.08–0.15), indicating
no measurable deficits in the foundational processing of Other neuropsychological domains. Five studies of neuropsy-
facial features (Buhlmann et al., 2004). Finally, another chological function indicated broadly similar neurocogni-
small study (n per group = 10) found five BDD and four tive profiles between BDD and OCD, particularly in
OCD participants reported perceived distortions in their domains of executive function. The most comprehensive of
own facial photographs when misled by the researchers to these studies utilised the Repeated Battery for the Assess-
believe the images may have been altered (Yaryura-Tobias ment of Neuropsychological Status (Toh et al., 2015a).
et al., 2002). This study found similar, significant impairment in both
BDD and OCD relative to healthy controls across domains
General visual processing. Five studies examined various of immediate memory and attention, but the three groups
aspects of visual processing. Of these, one found evidence did not differ across domains of visuospatial construction,
of greater detailed visual processing in BDD versus OCD language and delayed memory. In individual tasks, the
(Toh et al., 2017c), while the remainder variously demon- BDD group was significantly impaired compared to both
strated no differences between BDD and OCD in aesthetic the OCD and control groups for digit span and story recall,
detection (Hübner et al., 2016; Reese et al., 2010), visual while both the BDD and OCD groups were impaired rela-
organisation (Silverstein et al., 2015) or visual comprehen- tive to controls on story memory.
sion (Yaryura-Tobias et al., 2002). In the most recent study, A further study of executive function found similar
Toh et al. (2017c) investigated configural and detailed (i.e. impairment in BDD and OCD groups relative to healthy con-
piecemeal) visual processing using inverted Mooney faces trols in performance on the Tower of London Task and the
and objects. A significantly reduced inversion effect was Stroop Interference task, indicating executive dysfunction in
found for BDD relative to OCD (d = 0.62) and healthy con- both disorders (Hanes, 1998). However, no group differ-
trols (d = 0.83) for both face and object stimuli, while no ences were found in additional tasks of category fluency,
significant difference was observed between OCD and con- motor skill and memory function. Third, a small study (n = 10
trols (d = 0.18). Furthermore, the BDD group was signifi- per group) reported no differences between BDD, OCD and
cantly more accurate than the OCD (d = 0.66) and control healthy control participants in performance of the Wisconsin
(d = 0.77) groups in recognising inverted faces, while no Card Sorting Test, a measure of set-shifting abilities (Yaryura-
difference was found between OCD and controls (d = 0.11). Tobias et al., 2002). Finally, two studies of cognitive reason-
Overall, these findings indicate a greater use of detailed ing found no differences between BDD, OCD and healthy
visual processing in BDD than in OCD or controls. control participants in reality monitoring (Reese et al.,
Of two studies of aesthetic awareness, one found no dif- 2011b) or in the presence of a ‘jumping to conclusions’ bias
ferences between BDD, OCD and healthy control partici- for probabilistic reasoning tasks (Reese et al., 2011a).
pants for detection of facial symmetry (d range = 0.11–0.22)
and dot array symmetry (d = 0.15–0.40; Reese et al., 2010).
Discussion
Similarly, the second study reported no differences
between BDD, OCD, SAD and healthy control partici- The objective of this review was to provide a summary of
pants in the detection of subtle aesthetic changes to facial the research to date which has directly compared BDD and
features (d range = 0.13–0.50; Hübner et al., 2016). In OCD, to delineate areas of overlap or divergence between
terms of visual organisation, Silverstein et al. (2015) found the conditions. The 31 reviewed studies together demon-
no significant differences between BDD, OCD and healthy strated a broad array of findings of various strength, and
control participants in performance on the Ebbinghaus highlighted areas of overlap, areas of difference, and mixed
illusion and a contour integration test, with all groups sig- or unclear findings, as depicted visually in Figure 2. These
nificantly outperforming a schizophrenia group. However, interpretations were based on consistency of results across
ceiling effects may have occurred in the BDD, OCD and studies, calculated effect sizes for available comparisons
healthy control groups, which could have prevented detec- and consideration of study strengths and weaknesses.
tion of differences. Finally, the smallest study (n per However, given the small number of reviewed studies and
group = 10) reported no differences between BDD, OCD other limitations of the review, these interpretations are
and healthy control participants on the Picture Completion, necessarily tentative.
Block Design and Matrix Reasoning subtests of the Areas of convincing overlap between BDD and OCD as
Wechsler Adult Intelligence Scale III, indicating no meas- supported by convergent findings include sociodemographic
urable visual comprehension deficits in BDD or OCD features (e.g. marital status, employment status and educa-
(Yaryura-Tobias et al., 2002). Overall, these studies dem- tional attainment), average age of onset and illness course,
onstrate similarity between BDD and OCD in visual pro- severity of primary symptoms, functional impairment and
cessing areas of aesthetic detection, visual organisation fear of negative evaluation. Possible overlaps, as indicated

Malcolm et al. 1043
Figure 2. A visual depiction of conclusions regarding similarities and differences between BDD and OCD, and areas of mixed
or inconclusive findings. Conclusions were made on the basis of author agreement after taking into account the consistency
of findings across studies, individual study strengths and weaknesses, and calculated effect sizes for group comparisons (where
available).
either by single studies or partially inconsistent findings impairment with poor quality of life. Similarities in these
across multiple studies, include the severity of depressive features may indicate broad overlaps in patterns of illness
symptoms, perfectionism, disorder-relevant attentional manifestation between BDD and OCD, but they do not nec-
biases, normal general visual processing and similarly broad essarily signify analogous underlying mechanisms are pre-
yet mild impairments in neuropsychological function. sent in both disorders. For example, despite similarity in
Conversely, poor illness insight in BDD relative to OCD the overall mean age of BDD and OCD onset, significant
emerged as the starkest and most well-supported area of sex differences in the mean age of OCD onset have been
difference. Further probable differences, although sup- identified (i.e. significantly earlier for males than females;
ported by fewer studies or partially inconsistent findings, Ruscio et al., 2010). Conversely, the mean age of BDD
included association of BDD with greater social anxiety onset appears similar across the sexes (Phillips et al., 2006),
severity, biased facial affect recognition, greater detailed possibly indicating differential biological mechanisms (e.g.
visual processing, unique facial attractiveness judgements, sex hormone influenced) may be linked to the development
shame associations and interpretive biases, and disorgan- of each disorder. Moreover, contextualisation of these over-
ised visual scan strategies used during own-face viewing. laps between BDD and OCD within wider psychopathol-
In addition, mixed evidence of finely gradated differences ogy demonstrates that a variety of theoretically distinct
within broader similarities between BDD and OCD conditions also share similar symptom severity, age of
emerged in areas of proneness to delusional thinking, fear onset, illness course and associated impairment as BDD
of self, social cognition and visual scan strategies for unfa- and OCD (e.g. dysthymia, SAD, panic disorder, AN and
miliar faces. Finally, some research areas had a paucity of bulimia nervosa, several personality disorders; American
findings or mixed results and thus are inconclusive at pre- Psychiatric Association, 2013). As such, overlaps between
sent. These areas include treatment response, anxiety symp- BDD and OCD in these areas may not signal a particularly
tom severity, suicidality, childhood experiences of abuse unique relationship between the two disorders, but may
and patterns of comorbidities between BDD and OCD. reflect similarities across a large cluster of conditions.
Study of the mechanisms underlying development of simi-
lar general illness features may instead provide clarity in
Overlaps between BDD and OCD determining meaningful linkages across disorders.
The strongest evidence of similarity between BDD and The finding of similar symptom severity scores between
OCD suggests that the conditions share a general illness BDD and OCD indicates that disorder-specific symptomatic
template of severe and intractable mental illness, as charac- thoughts and behaviours in both disorders are associated
terised by moderate-to-severe symptom severity, illness with similar experiences of time depletion, distress, interfer-
onset in adolescence or young adulthood, a chronic and ence, irresistibility and involuntariness, as per the parallel
continuous illness course, and substantial functional nature of YBOCS and BDD-YBOCS items. As such, BDD

1044 ANZJP Articles
may share with OCD a fundamental symptom structure char- as to whether these alterations have an aetiological role or
acterised by persistent and powerfully compelling thoughts are sequelae of the condition (Abramovitch et al., 2013;
and behavioural urges, although with differing foci regarding Snyder et al., 2015). The neuropsychological profile of
cognitions and behaviours. However, a better understanding BDD has yet to be clearly established due to a paucity of
of the functional elements within this symptom structure is investigations, therefore comparisons to OCD in this
necessary to provide meaningful insights into the disorders, respect may be premature. Indeed, the relevant studies
which may be of use in treatment. For instance, empirical reviewed here were few in number, often narrow in scope
identification of a key functional relationship between obses- and possibly underpowered, warranting cautious interpre-
sions and compulsions in OCD (i.e. obsessions trigger anxi- tation of their findings. Nevertheless, findings suggest sim-
ety and compulsive urges, compulsions provide anxiety ilar dysregulation of prefrontal regions in both disorders,
relief) has been instrumental in forming effective cognitive- although a lack of impairment in other functions such as
behavioural treatment models of the disorder (Hodgson and verbal fluency and set-shifting ability is consistent with a
Rachman, 1972; Steven et al., 2011). However, BDD appears more complex interplay of dysfunctionality across wider
to differ from OCD in that symptomatic behaviours (e.g. brain networks in both conditions (Grace et al., 2017;
mirror checking) do not provide distress relief (Veale and Menzies et al., 2008).
Riley, 2001). In addition, burgeoning neurobiological data
regarding BDD thus far indicates important differences from
Divergences between BDD and OCD
OCD in terms of symptom correlates, particularly in altera-
tions of visual system regions and pathways involved in the Regarding differences between BDD and OCD, our find-
transfer and integration of cognitive, emotional and visual ings most prominently demonstrated worse illness insight
information in BDD (Beilharz et al., 2017; Grace et al., in BDD than in OCD. We speculate that worse insight in
2017). As such, further investigation of symptom function BDD might relate to the highly perceptual (i.e. appearance
and aetiology, rather than form, is essential to enhance our based) nature of BDD beliefs, while the often abstract
understanding of BDD. nature of OCD beliefs may permit more ‘malleable’ insight.
Other overlaps between BDD and OCD were found for For BDD, disturbances in visual processes might contribute
perfectionism, fear of negative evaluation and social anxi- to distortions of body image, which could reinforce disor-
ety severity, though these findings are based on few studies. dered beliefs relating to appearance defects (Beilharz et al.,
Although perfectionism is a transdiagnostic feature which 2017; Grace et al., 2017). In this sense, people with BDD
contributes to the development and maintenance of a vari- may perceptually ‘see’ what they believe to be true with
ety of disorders, including depression, anxiety and eating respect to their appearance – which in turn may act as an
disorders (Egan et al., 2011), it has been identified as a key especially convincing reinforcer of reduced insight.
construct in the cognitive processes of OCD and is theo- Concordantly, one study in this review demonstrated
rised to involve similar significance in BDD (Obsessive greater use of detailed visual processing in BDD than OCD.
Compulsive Cognitions Working Group, 1997; Veale, This result is consistent with previous findings of a behav-
2004). Perfectionism relating to idealised self-standards ioural bias towards detailed visual processing and hyperac-
may further contribute to a fear of negative evaluation and tivity of detailed-oriented visual systems in BDD (Beilharz
social anxiousness in both disorders, as well as disorder- et al., 2017). A bias for detailed visual processing in BDD
specific (i.e. differential) experiences of shame and fear of may also partly explain the finding of more disorganised
self. In addition, elevated scores for BDD and OCD in per- visual scan strategies in BDD versus OCD during own-face
fectionism sub-dimensions of ‘concern over mistakes’ and viewing. Reduced coherency of own-face scan strategies in
‘doubting of actions’ may further reflect a meaningful over- BDD has been previously linked to intensive selective
lap between the disorders, as higher scores in these domains attention towards and/or avoidance of preoccupying facial
have been linked to increasingly severe ‘not just right’ features (Greenberg et al., 2014; Grocholewski et al., 2012).
experiences (NJREs; Coles et al., 2003). Elevated NJREs Although speculative, we suggest that a bias for detailed
have been found in both BDD and OCD, with more severe visual processing combined with selective attention towards
NJREs being predictive of greater obsessional tendencies disliked appearance features might magnify distortions of
in OCD and non-clinical samples (Belloch et al., 2016; body image in BDD and might be an aetiologically impor-
Summers et al., 2017). As such, future comparisons might tant distinguishing feature of BDD relative to OCD.
find that BDD and OCD share similar patterns of interrela- Although supported by less consistent results, the review
tionships between these features. also demonstrated some support for impaired facial affect
Finally, both BDD and OCD appear to share similar, recognition in BDD versus OCD, especially for the misin-
mild impairments in broad neurocognitive functioning, par- terpretation of expressions of others, as anger. These results
ticularly in executive function. Modest impairments in align with those of previous studies of facial affect recogni-
executive function, processing speed and attention have tion in BDD (Buhlmann et al., 2011; Jefferies et al., 2012;
been previously established in OCD, but questions remain Labuschagne et al., 2011), as well evidence of mild yet

Malcolm et al. 1045
specific affect recognition impairments in OCD (Daros difference in continuum placement may reflect the pre-
et al., 2014). For BDD, affect recognition impairment might dominance of unusual beliefs or magical thinking styles
relate to visual processing disturbances, or overriding than often underpin OCD obsessions, while disordered
appearance preoccupations may divert visual attention beliefs in BDD appear circumscribed to appearance-based
away from features germane to affect identification (Toh concerns which involve less broad magical thinking styles.
et al., 2015b). In addition, misinterpretation of expressions Second, two studies found that neither BDD nor OCD
as anger in BDD may stem from negative expectations that demonstrate cognitive reasoning biases, which are often
others will be rejecting or hostile in response to perceived associated with psychosis. Together, these findings con-
flaws in one’s appearance (Buhlmann et al., 2006; Kollei trast with strong evidence of poorer illness insight in BDD
et al., 2012). As such, this anger misinterpretation bias than in OCD. As such, the current evidence seems to sug-
could relate to high social anxiety or problems with social gest that poor/absent insight in BDD and OCD may be best
cognition in BDD. conceptualised separately from (psychotic) delusionality
While both BDD and OCD clearly involve clinically and that magical thinking may have a differential role in
elevated social anxiety, careful interpretation of mixed OCD than in BDD.
comparative findings suggests there is more severe social
anxiety in BDD than in OCD. With this, BDD appears
Limitations
indistinguishable from SAD in the severity of social anxi-
ety symptoms (albeit with differing cognitions; that is, Although this review provides a comprehensive overview
body related in BDD, social performance in SAD), while of the comparative research between BDD and OCD to
social anxiety in OCD appears not to reach the same date, there are limitations which must be considered in
intensity. Furthermore, results from one study suggested interpretation of the findings. The relatively small number
that BDD may place relatively higher than OCD on a con- of studies, few replications and predominance of poten-
tinuum of social cognitive impairment, again with close tially underpowered studies in this review necessitate cau-
overlap between BDD and SAD. Finally, BDD was also tious interpretation and highlight the need for increased
associated with increased negative, self-focused interpre- comparative studies. Adding to this concern is the frequent
tative biases of social situations relative to OCD in one inclusion of individuals with BDD-OCD within BDD and
study. Although based on limited findings, we suggest that OCD groups, which may have obscured delineation of dif-
these studies (along with evidence of facial affect recogni- ferences between the disorders. Similarly, efforts to match
tion impairment in BDD) support a significant role of study samples across core demographic features may have
social-affective dysregulation in BDD as compared to obviated population-level differences in these features. In
OCD. Other work has demonstrated that self-evaluative addition, the absence of biological comparisons in this
concerns in BDD are frequently accompanied by equally review represents a significant gap in our understanding of
important and anxiety-provoking socio-evaluative con- possible interrelationships or divergences between BDD
cerns (Anson et al., 2012) and that individuals with BDD and OCD, as these investigations are essential in forming a
endorse strong fear of social consequences such as rejec- nuanced understanding of the links between clinical pres-
tion, humiliation and isolation contingent on other’s eval- entation features and underlying biological aetiological
uations of their appearance (Veale et al., 1996). As such, mechanisms (Cuthbert, 2014). Finally, the lack of treat-
greater attention to social-affective dysregulation in the ment research included in this review represents a signifi-
clinical treatment of BDD may enhance treatment out- cant limitation, as such studies are essential for establishing
comes. In particular, treatment strategies for SAD may the relative efficacy of certain interventions (e.g. cogni-
have translational value in addressing social-affective tive-behavioural therapy, medications) across BDD and
aspects of BDD concerns. However, there is a need for OCD. In particular, the current classification of BDD as an
fine-grained investigations of the operative role of social- Obsessive Compulsive Related Disorder may lead clini-
affective dysregulations in both BDD and OCD, as both cians to apply similar treatment models to both OCD and
conditions present with clinically significant social anxi- BDD, but the utility of shared approaches remains to be
ety, and a minority of individuals with BDD have no investigated. Given these limitations, there is a clear need
socio-evaluative concerns (Veale, 2004). for further comparative investigation of BDD and OCD,
Finally, the review findings indicate subtle differentia- particularly in biological domains, treatment and other
tion between reduced insight and proneness to cognitive areas (e.g. phenomenology and cognition) which may
styles associated with psychotic delusions in both BDD uncover core and transdiagnostic features in the disorders.
and OCD. First, OCD appeared to place higher than BDD Importantly, this work should be well-powered, replicative
on a continuum of proneness to delusional thinking styles and expansive upon current studies and rigorous in
when compared to controls and schizophrenia patients (i.e. accounting for the presence of BDD-OCD within sample
OCD indistinguishable from schizophrenia). This subtle groups.

1046 ANZJP Articles
Future research and conclusion neurobiological features. Data from such research will
This review demonstrates a need for further theoretical and determine the specificity of observed similarities between
empirical evaluation of current models of BDD, and the BDD and OCD, and between BDD and other disorders,
nosological standing of BDD as belonging within the thus providing broad and balanced information in the
Obsessive-Compulsive and Related Disorders category. development of better theoretical models of BDD.
While the reviewed evidence corroborates some claims of Furthermore, the review highlighted numerous areas of
similarity between BDD and OCD as made by research both overlap and difference between BDD and OCD (e.g.
groups involved in development of the DSM-5, particularly social cognition, fear of self and proneness to unusual think-
in the areas of symptom severity, average age of onset and ing). These findings demonstrate the need for a dimensional
illness course, there was no clear comparative evidence to approach in the study of overlaps between disorders, rather
support claims of similarity in several other listed areas, than simple identification of categorical similarities or differ-
including familiality, neurobiology, biomarkers, temporal ences. While the current categorical approach of the DSM
antecedents and responsiveness to serotonin reuptake has had pragmatic success in providing a framework for
inhibitors (Phillips et al., 2010). As such, our review find- research, treatment and management of psychological condi-
ings lead us to suggest that the current classification of tions, the system inherently dissuades a multidimensional
BDD within the Obsessive-Compulsive and Related approach in the understanding of psychopathology. BDD is
Disorders category may not be the most appropriate. Other quite clearly a distinct yet multidimensional disorder involv-
evidence has indicated that BDD shares many dimensional ing strong overlaps with multiple other conditions, and as
similarities with other conditions such as SAD and AN, but such is not simple to categorise within the DSM hierarchy
these linkages have been much less studied (Fang and (Schneider et al., 2018). Alternate approaches such as the
Hofmann, 2010; Hartmann et al., 2013). As such, it is pos- Research Domain Criteria system, which emphasises a
sible that the conceptualisation of BDD as an Obsessive- cross-diagnostic dimensional approach to psychiatric
Compulsive and Related Disorder is in part a product of research, may be better suited to improving our understand-
intensive research focus on links between BDD and OCD, ing of complex conditions (Cuthbert and Insel, 2013).
to the exclusion of other possible linkages. For example, Elucidation of the relative positioning of BDD and other dis-
BDD and AN share core psychological components of disorders along various illness dimensions within such an
torted body image, poor illness insight, intense overvalua- approach can help to clarify the complexity of BDD and
tion of appearance and body-focused behaviours more accurately crystallise our conceptualisations of the
specifically intended to check, change or hide disliked bod- condition. Furthermore, this intuitive dimensional approach
ily features (Hartmann et al., 2013). The disorders also is essential in advancement towards precision medicine,
share abnormalities in visual system functioning, particu- which is anticipated to provide improved treatment outcomes
larly regarding detail-oriented visual systems, which has for complex conditions such as BDD (Cuthbert, 2014).
been theorised to link in to body image preoccupations in In sum, the present review provides limited support for
both disorders (Li et al., 2015a, 2015b). As such, BDD conceptualisation of BDD as belonging within the
might be better classified as a ‘body image disorder’, Obsessive-Compulsive and Related Disorders category, as
closely related to AN (Haliburn, 2018; Phillipou et al., adapted in the current DSM-5. Evidence of shared features
2017). In particular, the muscle dysmorphia subtype of between BDD and OCD appear to largely reflect a broad
BDD has been hotly contested in this respect (dos Santos template of severe, intractable mental illness, and the pres-
Filho et al., 2016; Murray and Touyz, 2013; Phillipou et al., ence of transdiagnostic features which may be common to
2016). In addition, BDD and SAD share many overlaps in many psychopathologies. Several areas of difference
clinical features, including severe social anxiety, avoidant between BDD and OCD were identified which may reflect
and safety-seeking behaviours, threat-based interpretations divergences in aetiopathogenesis between the disorders. In
of ambiguous information and responsiveness to very simi- particular, BDD appears associated with poorer illness
lar modalities of cognitive-behavioural therapy (Fang and insight, increased detail-oriented visual processing,
Hofmann, 2010). As such, BDD might also be conceptual- impaired and anger-biased facial affect recognition, ele-
ised as an anxiety disorder, just as OCD had been up until vated social anxiety and possibly broader social-affective
publication of DSM-5. Indeed, some researchers have sug- dysregulation. As such, we suggest that the current nosolog-
gested that overlaps between BDD and OCD reflect shared ical standing of BDD within the Obsessive-Compulsive
anxiety-driven pathology (Abramowitz and Jacoby, 2015; and Related Disorders category deserves further research
Stein et al., 2010). Regardless, it is clear that further investigation and re-evaluation in future. Specifically,
research is required to better inform any future classifica- research which elucidates underlying illness mechanisms
tion of BDD. Thus, future research should investigate rela- in BDD and their connections to clinical presentation, and
tionships between BDD and OCD, and disorders other than clarifies complex dimensional linkages between BDD and
OCD (e.g. AN, SAD) in areas that may relate to core other disorders, will be essential in improving our under-
pathology, such as underlying psychological, cognitive and standing and treatment of BDD.

Malcolm et al. 1047
Acknowledgements and obsessive-compulsive disorders. Journal of Anxiety Disorders 34:

107–113.
A.M. would like to acknowledge the support of the Australian Buhlmann U, Wilhelm S, McNally RJ, et al. (2002) Interpretive biases for
Government Research Training Program Scholarship during prep- ambiguous information in body dysmorphic disorder. CNS Spectrums
aration of this publication. P.G.R. would like to acknowledge sup- 7: 435–436, 441–443.
port of an Australian Catholic University Research Fund Program Carleton R, McCreary D, Norton P, et al. (2006) Brief fear of negative
Grant during his contribution to this publication. evaluation scale-revised. Depression and Anxiety 23: 297–303.
Castle D and Phillips K (2006) Obsessive-compulsive spectrum of disor-
Declaration of Conflicting Interests ders: A defensible construct? Australian and New Zealand Journal of
Psychiatry 40: 114–120.
The author(s) declared no potential conflicts of interest with respect Chosak A, Marques L, Greenberg JL, et al. (2008) Body dysmorphic
to the research, authorship and/or publication of this article. disorder and obsessive–compulsive disorder: Similarities, differences
and the classification debate. Expert Review of Neurotherapeutics 8:
Funding 1209–1218.
Clerkin EM, Teachman BA, Smith AR, et al. (2014) Specificity of implicit-
The author(s) received no financial support for the research,
shame associations. Comparison across body dysmorphic, obsessive-
authorship and/or publication of this article. compulsive, and social anxiety disorders. Clinical Psychological
Science 2: 560–575.
ORCID iD Coles ME, Frost RO, Heimberg RG, et al. (2003) ‘Not just right expe-
Izelle Labuschagne https://orcid.org/0000-0002-1590-0947 riences’: Perfectionism, obsessive–compulsive features and general
psychopathology. Behaviour Research and Therapy 41: 681–700.
Cuthbert BN (2014) The RDoC framework: Facilitating transition from
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799925 ANP ANZJP ArticlesMalcolm et al.

Australian & New Zealand Journal of Psychiatry

The relationship between body 2018, Vol. 52(11) 1030­–1049

dysmorphic disorder and obsessive- © The Royal Australian and

compulsive disorder: A systematic Article reuse guidelines:

Amy Malcolm1, Izelle Labuschagne1 , David Castle2,3,

1Cognition and Emotion Research Centre, School of Psychology,

and controversial classification of BDD within the new VIC, Australia

Australian & New Zealand Journal of Psychiatry, 52(11)

camouflaging of appearance, and mentally comparing appear- Method

Australian & New Zealand Journal of Psychiatry, 52(11)

independent diagnostic entities of BDD and OCD. In Clinical characteristics

Australian & New Zealand Journal of Psychiatry, 52(11)

Authors n Groups Key findings Study strengths Study weaknesses

Buhlmann et al. 19 BDD Negative interpretations in body- Excluded BDD- No OCD-relevant

Australian & New Zealand Journal of Psychiatry, 52(11)

Authors n Groups Key findings Study strengths Study weaknesses

Australian & New Zealand Journal of Psychiatry, 52(11)

Authors n Groups Key findings Study strengths Study weaknesses

53 OCD No difference in employment, living

Australian & New Zealand Journal of Psychiatry, 52(11)

Authors n Groups Key findings Study strengths Study weaknesses

Australian & New Zealand Journal of Psychiatry, 52(11)

Authors n Groups Key findings Study strengths Study weaknesses

Australian & New Zealand Journal of Psychiatry, 52(11)

Australian & New Zealand Journal of Psychiatry, 52(11)

Australian & New Zealand Journal of Psychiatry, 52(11)

Australian & New Zealand Journal of Psychiatry, 52(11)

Australian & New Zealand Journal of Psychiatry, 52(11)

Australian & New Zealand Journal of Psychiatry, 52(11)

Australian & New Zealand Journal of Psychiatry, 52(11)

Australian & New Zealand Journal of Psychiatry, 52(11)

Australian & New Zealand Journal of Psychiatry, 52(11)

Australian & New Zealand Journal of Psychiatry, 52(11)

Acknowledgements and obsessive-compulsive disorders. Journal of Anxiety Disorders 34:

Australian & New Zealand Journal of Psychiatry, 52(11)

Australian & New Zealand Journal of Psychiatry, 52(11)

Australian & New Zealand Journal of Psychiatry, 52(11)

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1Cognition and Emotion Research Centre, School of Psychology,