Proportion of body dysmorphic disorder among medical students in a tertiary care teaching hospital: A cross-sectional study

INTRODUCTION

Body dysmorphic disorder (BDD) is “a mental health condition where a person spends a lot of time worrying about flaws in their appearance.” These flaws are often unnoticeable to others.^[1]

Individuals with BDD often have a negative perception of their own body image that leads to significant negative emotions, thus affecting their daily functioning. People spend a lot of time juxtaposing their looks with others, stare at mirrors looking at themselves, or avoid mirrors altogether, and make multiple efforts to camouflage their flaws. A person with BDD shows excessive worrying about their body parts, and they tend to recheck themselves in front of mirrors and cover their body parts. It can start as a shame towards your own body and then can progress gradually to grievous consequences.^[1]

Most of us have imperfections in us, but when these flaws create an overwhelming reaction in a person, then these are said to be BDD. People affected with BDD do undergo multiple cosmetic procedures to correct their perceived imperfections. Fear of judgment built in them can lead them to avoid social gatherings.^[2] If left untreated, BDD can generate severe depression and suicidal thoughts.^[3]

Diagnosing BDD is the first step for treatment.^[1] A limited number of studies are available regarding the screen-positive proportion and magnitude of BDD in college students, particularly medical students. Body image dissatisfaction was quite high in the medical students in a study conducted by Taqui et al, in which the majority of the students reported that they were concerned about some aspect of their appearance.^[1,4]

The main intention of this study is to estimate the screen-positive proportion of BDD among the medical students in a tertiary care teaching hospital in South Kerala, India, and also to find the socio-demographic profile of students screened positive for this disorder. Our study also aims to decrease the incidence of grievous effects of this disorder, such as self-doubt, depression, and suicide.

MATERIALS AND METHODS

RESULTS

The mean age of the study population was found to be 21.47±1.48 years. Our study population included the majority of female medical students, forming 65.5 % (131) of the participants (N=200). The mean height of the study population was found to be 164.23±9.8 centimeters. The mean weight of the study population was found to be 61.13±13.87 kilograms.

The mean BMI of the study population was found to be 22.48 ± 3.71, as depicted in Table 1. The median time of the 182(91%) participants was found to be under an hour. Only 18(9%) participants had a mirror time over 1hour. Among the study population, 143(71.5%) participants were bothered about their hair, 72(36.0%) participants were concerned about being fat, and 30(15.0%) participants were concerned about being thin.

Graph 1 implies that among 200 study participants, 95 (47.5%) individuals were bothered about acne or scars, followed by 42(21.1%) participants with other skin issues, 18(9%) participants with wrinkles, and 15(7.5%) participants

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Graph 1: Bothered about skin (N=200).

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Graph 2 implies that among 200 participants, 65(32.7%) individuals were bothered about shape of abdomen, followed by 39(19.6%) individuals about nose, 38(19.1%) participants about hips, 27(13.6%) individuals about mouth, 24(12.1%) individuals about lips and 21(10.6%) individuals about shape of jaw.

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Graph 2: Bothered about the shape of body parts (N=200).

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Among 200 participants, 20(10.1%) individuals were bothered about parts of the body other than the genitals, breast, and hand. Our study concluded that more than half of the study population were not bothered by any body part in particular, as depicted in Graph 3.

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Graph 3: Bothered about various body parts (N=200).

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Among the 200 participants, 67 participants responded positively to the BDDQ scoring questionnaire, and they were administered the subsequent questions. Therefore, n changes to 67. Among the 67 participants who positively responded to BDDQ, 18 participants had a score of 4 points or above, which is regarded as positive for BDD according to BDDQ.

Our study concluded that 9% of the medical students screened positive for BDD using BDDQ. Among the 67 students who expressed concerns about body image, primary concerns were related to overweight/obesity (p = 0.004, OR = 6.41, 95% CI: 1.89–21.74) and shape of lips (p = 0.021, OR = 4.33, 95% CI: 1.35–13.91) as depicted in Table 2.

DISCUSSION

Our study suggests that 18(9%) participants screened positive for BDD using BDDQ, while the majority of the participants do not reveal any signs of BDD. The proportion of positively screened BDD participants found in our study is consistent with the findings of a cross-sectional study conducted in Goa among 378 students of a medical college, where the prevalence of BDD was found to be 6.9%.^[7]A similar study was done in Kerala among medical students, which estimated a screen-positive proportion of 18%.^[8]The screen-positive proportion of BDD is higher in our study as compared to the cross-sectional study conducted among 156 medical students in Pakistan.^[4]The higher proportion of positively screened BDD participants among our study population could be attributed to various factors. Societal norms warrant better grooming and emphasis on the appearance of doctors at the workplace, which is thereby followed in medical colleges to ensure implementation of the same as the students graduate into health practitioners.^[4]

The most common foci of concern among the participants were found to be regarding hair. This finding can be attributed to the portrayal of well-groomed individuals in the media that distorts the perceived body image and fosters a feeling of mismatched body proportions. As the exposure to media starts from a very young age, the concepts of a healthy body, once distorted, are ingrained since childhood unless addressed. The forms of media that are widely available encompass advertisements of hair products on social media platforms with celebrity and influencer handles that simulate unrealistic beauty standards.^[9]Among the skin issues, acne poses a major concern among our study population. This finding is in line with the findings of a cross-sectional, double-center study among 156 study participants in Amsterdam. The aforementioned study revealed that 12.4% of young adult participants diagnosed with acne vulgaris were screened positive for BDD. These findings imply that adults seeking health care advice for self-assessed skin problems are an at-risk group for BDD.^[10] The majority of the study population were bothered by the shape of the abdomen. Participants with overweight or obesity had significantly higher odds of BDD as assessed by our study. This finding was consistent with the findings of an empirical study conducted among 200 individuals, where 13% of the participants were insecure about their abdomen. The entry of ‘diet-culture’ and ‘fat phobia’ into the daily conversations of young adults in the recent past has facilitated the emergence of symptoms of BDD.^[11] Literature points out fixation on symmetry or perfectionism of various body parts among individuals with BDD. The majority of our study population were not concerned about any particular body part. This spared the study individuals from critical inner dialogue and scrutiny, contrary to the findings from various qualitative studies conducted among young adults.^[12,13]

Avoidance and concealment are various safety-seeking measures or behavior patterns observed in individuals who are likely to develop BDD.^[12] These practices were reported by fewer than half of the study population. However, comparison of perceived flaws with people around and in magazines or on television adds to the likelihood of developing BDD. This finding is in line with the findings of our study population. Feeling of internal shame and a need for external validation among the young adults poses a challenge in overcoming the proportion of BDD among young adults.^[14]

Orthodontic treatments are of great popularity among young adults to whom body image is relevant. In a cross-sectional study conducted among 1184 patients who sought orthodontic procedures, 5.2% individuals were screened positive for BDD. Among individuals concerned about their body, the head and face are common areas of concern.^[15] Appearance comparison and fixation on physical defects is a common behavior observed among individuals with BDD.^[16]

Our study did not reveal any significant association between concern regarding the shape of the jaw and the screen-positive proportion of BDD. Rise in awareness regarding orthodontic and cosmetic procedures has led to a significant increase in these procedures for concerns of the jaw, which is contrary to our findings.^[15] Studies in the past concluded that a focus of concern among patients with BDD is the shape of the lips.^[17] Similar conclusions were drawn from our study. Concern over any defect in the breast was not found to be associated with the screen-positive proportion of BDD among our study population. This finding is contrary to the conclusion of a cross-sectional study conducted among higher secondary school students in Imphal. Concerns and insecurities experienced during adolescence often persist into adulthood, contributing to the development of BDD in many individuals. Therefore, it is essential to integrate greater awareness and support for BDD within school and mental health programs to promote early intervention and prevention.^[18,19]

CONCLUSION

According to our study, out of the 200 participants, 18 students (9%) were screened positive for BDD according to BDDQ. Among the 67 students who expressed concerns about body image, primary concerns were related to overweight/obesity (p = 0.004, OR = 6.41, 95% CI: 1.89– 21.74) and shape of lips (p = 0.021, OR = 4.33, 95% CI: 1.35– 13.91).

These results highlight the urgency to address issues with body image and mental health among students, underlining the need for targeted remedies. Therefore, more research is advised to ascertain the scope of the issue, and BDD should receive greater attention in school and mental health initiatives.