Journal of Human Behavior in the Social Environment

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Psychosocial risk and body dysmorphic disorder: A

systematic review

Gayle Mallinger & Austin Weiler

To cite this article: Gayle Mallinger & Austin Weiler (2020) Psychosocial risk and body dysmorphic
disorder: A systematic review, Journal of Human Behavior in the Social Environment, 30:8,
1030-1044, DOI: 10.1080/10911359.2020.1790463

To link to this article: https://doi.org/10.1080/10911359.2020.1790463

Published online: 31 Aug 2020.

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JOURNAL OF HUMAN BEHAVIOR IN THE SOCIAL ENVIRONMENT
2020, VOL. 30, NO. 8, 1030–1044
https://doi.org/10.1080/10911359.2020.1790463

Psychosocial risk and body dysmorphic disorder: A systematic

review
Gayle Mallinger and Austin Weiler
Department of Social Work, Western Kentucky University, Bowling Green, Kentucky, USA

ABSTRACT KEYWORDS
Body dysmorphic disorder (BDD) is a psychiatric diagnosis character­ Body dysmorphic disorder;
ized by a debilitating preoccupation with perceived appearance BDD; systematic review;
defects that are not noticeable to others. The International OCD psychosocial risk
Foundation estimates nearly 1 in 50 individuals in the United States
meet the diagnostic criteria for this disorder; however, despite its
prevalence, many social work professionals lack familiarity with this
diagnosis. Using PRISMA-P reporting guidelines, this article presents
a systematic review of studies examining individual, interpersonal, and
environmental risks in the development of BDD. Implications for social
work practice and suggestions for further research are discussed.

Introduction
Body dysmorphic disorder (BDD) is a psychiatric diagnosis characterized by a debilitating
preoccupation with perceived physical defects not noticeable to others (American
Psychiatric Association [APA], 2013). Consequent anxiety related to the perception of
abnormal appearance leads to excessive grooming, constant mirror checking, and other
obsessive behaviors. Fearing ridicule or exclusion, individuals with BDD are likely to exhibit
signs of social anxiety and avoidant behaviors. Typically beginning in early adolescence, this
disorder causes significant impairment in social, educational, occupational, and family
functioning of males and females (Bjornsson et al., 2013). Due to its chronicity, BDD
continues through adulthood with increasingly dire consequences. (Mataix-Cols et al.,
2015; Phillips et al., 2013).
The International Obsessive-Compulsive Disorder Foundation (2017K. A. Phillips 2020)
estimates nearly 1 in 50 people in the United States meet the diagnostic criteria for this
condition. Anxiety and mood disorders, including major depression, obsessive-compulsive
disorder, and social phobia, are highly correlated with BDD (Gunstad & Phillips, 2003).
Physical aggression and violence are also associated with this diagnosis. In addition,
individuals with BDD are at significant risk for substance abuse disorders and eating
disorders, particularly anorexia nervosa (Behar et al., 2016; Bjornsson et al., 2013).
Suicidal ideation, attempts, and completed suicides are also consequences of severe BDD
(Angelikis et al., 2016; Phillips et al., 2013).
Studies suggest external influences are significant contributors to BDD. Body dissatisfac­
tion, a prominent feature of the disorder, is affected by societal values. Family, peers, social
media, and other environmental impacts determine attitudes toward one’s own physical

CONTACT Gayle Mallinger gayle.mallinger@wku.edu Western Kentucky University, Bowling Green, KY 42101, USA
© 2020 Taylor & Francis Group, LLC
 JOURNAL OF HUMAN BEHAVIOR IN THE SOCIAL ENVIRONMENT 1031

characteristics. Prevailing cultural expectations and context also impact body part focus;
thus, manifestations of BDD are heavily influenced by cultural beauty norms and often
inform areas of concern. For example, in Japan, the disorder is often expressed in an
extreme preoccupation with eyelids, while muscle dysphoria is more common in the
United States (Fang & Hofman, 2010; Sreshta et al., 2017). Likewise, while American
women diagnosed with BDD are concerned with the appearance of their thighs, legs, and
breasts, Brazilian women seek rhinoplasty (Ramos et al., 2016).
Although the overall prevalence in the general population does not differ by gender,
expectations about beauty influence BDD expression (Gupta et al., 2013). American culture
pressures men to be strong and buff, which heightens their risk for muscle dysphoria. Men
are also more likely to be concerned with thinning hair. Conversely, women tend to
demonstrate an increased preoccupation with breasts, hips, skin, and facial features com­
pared to their male counterparts (Tyagi et al., 2013). Race/ethnicity and sexual orientation
are also risk factors for developing BDD. European American and Latinx individuals have
higher rates of BDD compared to other racial and ethnic groups. Similarly, lesbian women
and gay men are also differentially affected (Boroughs et al., 2010).
Various factors increase risk for BDD. Having a first degree relative with a diagnosis of
BDD and/or OCD heightens danger for developing this disorder (Enander et al., 2018). Co-
occurring diagnoses, including social anxiety and depression, also raise the probability of
acquiring BDD (Barahmand & Shahbazi, 2015; Mastro, Zimmer-Gembeck & Webb, 2016).
Adverse childhood experiences are associated with its occurrence as well. In adolescents,
symptoms were found to be highly correlated with appearance teasing by peers and were
significantly more pronounced for teens reporting harassment by opposite-sex peers (Webb
et al., 2015). Emotional, physical, and sexual abuse are also specific risk factors for BDD
(Veale et al., 2015). In fact, Didie et al. (2006) reported over three-fourths of study
participants reported child maltreatment. They also found perceived sexual abuse severity
strongly correlated with the severity of BDD symptoms. Although BDD is considered
a chronic diagnosis with high probability of relapse, full remission is linked to early
diagnosis and treatment (Phillips et al., 2013).
Despite its substantial prevalence and seriousness, social workers lack familiarity with
BDD. Although the average age of onset is 16, the mean age of diagnosis is not until 34
(Bjornsson et al., 2013). Among the reasons for this delay is the pursuit of initial consulta­
tions with cosmetic surgeons or dermatologists (Metcalfe et al., 2014). Additionally, many
clients do not spontaneously discuss indicators of the disorder with professionals. Instead,
they seek services for co-morbid disorders (Schneider et al., 2017). In their roles in health
and mental health systems, social workers are key in identifying and treating BDD. Social
work professionals can also effect changes in mezzo and macro contexts, including advo­
cacy for policies impacting this underserved population (Wolrich, 2011).
Empirical evidence supports the efficacy of early treatment in reducing or eliminating
symptoms of BDD. Social workers have a unique understanding of the biological-
psychological-social-spiritual-cultural perspective in health and mental health problems,
and are thus well-positioned to recognize psychosocial factors that put individuals at risk.
Identifying clients in jeopardy of developing BDD is an important step in preventing
chronic and serious outcomes. There is, however, a dearth of social work literature about
this issue. This study reviews and synthesizes empirical research pertaining to psychosocial
correlates of BDD in the United States. The primary aim of this work is to assist social work
1032 G. MALLINGER

professionals in gaining knowledge about the disorder, with specific attention to predis­
posing influences. Understanding this serious disorder and its accompanying risk factors
can lead to early intervention and protect against adverse outcomes.

Methods
This review has been conducted according to the Preferred Reporting Items for Systematic
Reviews and Meta-Analyses Protocols (PRISMA-P), outlined by Moher et al. (2015). These
guidelines are designed to systematically and transparently identify, evaluate, and summar­
ize literature across professions. The final review is conveyed according to PRISMA-P
guidelines (Moher et al., 2009).

Inclusion/exclusion criteria
Inclusion and exclusion criteria were determined in advance. Studies had to satisfy the
following criteria: (a) sample participants in the United States diagnosed with of BDD (b)
variables include psychosocial risk factors, and (c) published as an original peer-reviewed
article. Studies that were (a) conceptual or theoretical, (b) dissertations, or (c) not published
in English were excluded from consideration (Table 1).

Review process
Social work is a multidisciplinary field; therefore, pertinent research findings are not
limited to publications in social work journals. The authors enlisted the assistance of
a university librarian well-versed in systematic reviews to develop effective search
strategies for this study. The databases, searched in November 2019, used for this
review include: Academic Search Complete, APA PsycInfo, PubMed, Social Service
abstracts, and Web of Science. In order to maximize the potential number of studies,
a Boolean search strategy was employed using the following key words and phrases:
Body Dysmorphic Disorder, BDD, Risk, Risk Factors, Contributing Factors, and
Predisposing Factors. To maximize the number of possible citations, a date range of
1999 to 2019 was applied to all database searches. Initial electronic searches generated
491 studies for consideration: Academic Search Complete (n = 97), APA PsycInfo,
(n = 126), PubMed, (n = 77), Social Service Abstracts (n = 32), and Web of Science
(n = 159).
Screening forms were developed and completed for all studies deemed potentially eligible
using the aforementioned criteria. All information was recorded on spreadsheets and
duplicates were removed. To evaluate for eligibility, the authors then conducted an abstract

Table 1. Inclusion criteria.

Category Category
Location United States
Language English
Date of Publication 1999–2019
Sample Individuals diagnosed with BDD
Predictor Variable Psychosocial Risk Factors
 JOURNAL OF HUMAN BEHAVIOR IN THE SOCIAL ENVIRONMENT 1033

review of the remaining 398 articles. Each author independently screened and assessed
studies from the five selected databases. Those not relevant to this study were eliminated.
The authors selected and coded the remaining articles; if the researchers differed about
article inclusion and/or data extraction, decisions were made by consensus. If disagree­
ments persisted, a third reviewer was designated as the decisionmaker; however, any
difference of opinion was resolved by the two authors.
To maintain the emphasis on psychosocial influences, research where BDD was the
independent variable was also excluded. Additionally, studies focused on general anxiety
disorders, eating disorders, or obsessive-compulsive disorders were removed from consid­
eration. Searches for BDD also yielded research on bovine disease, brain death, and other
issues irrelevant to this study and were excluded as well. Several publications using over­
lapping samples, but with unique results, were included in this study.

Results
Search and screening processes are detailed in Figure 1. Nine of the 24 studies initially
screened are excluded, as they were unrelated to the target population or did not examine
the factors of interest. The 15 studies meeting eligibility criteria are included in this review.
Summaries of investigations, including authors, dates of publication, sample characteristics,
measures, and key findings are provided in the table (Table 2).

Study characteristics
The 15 articles included in this review represent distinct studies published in 12 different
clinical journals from 2002 through 2019. The majority issued within the past 5 years, likely
reflective of an emerging interest in BDD. Sample sizes ranged from 37 to 10,962. The two
studies with over 1,000 participants utilized data from the National Longitudinal Study of
Adolescent Health (Kimber et al., 2015) and a subset of a longitudinal sample originally
recruited from 11 low-income public middle schools in Los Angeles (Guzman & Nishina,
2013). Five were comparative studies (Blum et al., 2018; Buhlmann et al., 2012; Greenberg
et al., 2014, 2018; Neziroglu et al., 2006) examining the differences between those meeting
the diagnostic criteria for BDD and healthy controls with similar demographics.

Participant characteristics
The mean ages across studies ranged from 14.2 to 39.7 years. Two studies did not report this
demographic (Guzman & Nishina, 2013; Patton et al., 2014). Of the 12 studies reporting
age, three focused specifically on adolescents (Buhlmann et al., 2012; Cafri et al., 2006;
Kimber et al., 2015). Three studies included all male participants (Cafri et al., 2006; Klimeck
et al., 2018; Walker et al., 2009) with one exclusively female (Patton et al., 2014). Of the
eleven studies reporting on race/ethnicity, 10 reported a majority of White/Caucasian
participants and one reported primarily Latinx participants (Guzman & Nishina, 2013).
1034 G. MALLINGER

Identification Records identified through database Additional records identified through

searching other sources
(n = 491) (n = 0)

Records after duplicates removed

(n = 398)
Screening

Records screened Records excluded

(n =398) (n = 374)
Eligibility

Full-text articles assessed for Full-text articles excluded,

eligibility with reasons
(n = 24) (n = 9)
Included

Studies included in synthesis

(n = 15)

Figure 1. PRISMA-P.

Key findings and synthesis of the results

Of the 15 articles included in this review, all but two (Guzman & Nishina, 2013; Neziroglu
et al., 2006) used standardized measures to assess constructs of interest. Several of the
studies used the same measures to confirm a diagnosis of BDD. Three studies employed the
Body Dysmorphic Questionnaire (Blum et al., 2018; Weingarden et al., 2017; Weingarden,
Curley, et al., 2016) and four utilized the Body Dysmorphic Disorder Modification of the
Yale-Brown Obsessive-Compulsive Scale (Buhlmann et al., 2012; Fang et al., 2019;
Greenberg et al., 2014, 2018).
The reviewed studies examined a variety of factors associated with BDD. Risk and
resilience theory can be used as a structure to categorize psychosocial correlates identified
in this analysis. Specifically, in this circumstance risk refers to proximal (individual) and
distal (interpersonal and contextual) stressors placing individuals in danger of developing
and exacerbating symptoms of BDD (Fraser et al., 2004). Thus, the psychosocial correlates
discussed in this narrative synthesis will be organized across proximal and distal domains,
as shown in Table 2.
 JOURNAL OF HUMAN BEHAVIOR IN THE SOCIAL ENVIRONMENT 1035

Table 2. Key findings.

Risk
Participant Proximal.
Authors N Characteristics Measures Key Findings Distal
Blum et al. N = 82 Gender 38 female/44 Hamilton Anxiety Rating At-risk subjects X
(2018). male Age 18–29 (BDD Scale (HAM-A) performed
group mean age 25.4, Hamilton Depression significantly worse on
SD-3.9; Control group Rating Scale (HAM-D) a measure of
mean age 22.2, Body Dysmorphic executive function,
SD = 3.7)Race 62 Disorder suggesting selective
White/Caucasian 20 Questionnaire (BDDQ) cognitive dysfunction
non-White/Caucasian Cambridge may already be
Neuropsychological present in those at
Test Automated risk of developing
Battery (CANTAB): BDD.
Executive
FunctionCambridge
Gambling Task (CGT)
One Touch Stockings
of Cambridge (OTS)
Spatial Working
Memory (SWM)
Buhlmann N = 37 Gender 30 female/7 SCID (Structured Clinical The group with BDD X
et al. (18 BDD/19 male (14 female/4 Interviews for DSM-IV reported more
(2012). control) male in BDD/16 -TR)Body Dysmorphic traumatic events,
female/3 male Disorder Modification including experiences
control)Age 10–19 (BDD) of the Yale- of sexual and physical
with mean age 14.2 Brown Obsessive- abuse in childhood or
(SD = 2.3 years)Race Compulsive Scale adolescence than did
unknown (YBOCS)Beck healthy controls.
Depression Inventory
(BDI-II)Short version
of the Traumatic
Stress Institute Life
Event Questionnaire
(LEQSF)
Cafri et al. N = 269 Gender 269 maleAge Body Mass Index (BMI) Negative affect, media XX
(2006). Two 13–18 with mean age Pubertal influence, and power
hundred 14.64 Development Scale sports participation
sixty-nine (SD = 1.03 years)Race Media Influence Scale significantly
boys 72% Caucasian, for Adolescent Boys predicted symptoms
ranging in 14% Hispanic, Teasing about of muscle
age from 4.5% African Muscularity dysmorphia.
13 to 18 American, Negative Affect Scale
(M = 14.64, 1.5% Asian, Rosenberg Self-
SD = 1.03) 6.4% other, Esteem Inventor
1.5% non-responders. Drive for Muscularity
Scale-Body Image
Subscale
Muscle Appearance
Satisfaction Scale
(MASS)
Participation in power
sports
Substance Abuse
Dieting to Gain
Weight Subscale of
the Body Change
Inventory
(Continued)
1036 G. MALLINGER

Table 2. (Continued).
Risk
Participant Proximal.
Authors N Characteristics Measures Key Findings Distal
Fang et al. N = 65 Gender SCID-II (Structured BDD is associated with X
(2019). Female 44 (67.7%) Clinical Interviews for high levels of
Male 21 (33.3%) DSM-IV Axis II neuroticism and low
Age: 34.60 (13.88) Personality Disorders) levels of extraversion.
Ethnicity/Race BDD-YBOCS (Yale- In addition, greater
Caucasian 57 (87.7) Brown Obsessive- numbers of
African American 5 Compulsive Scale personality disorders
(7.7) Modified for BDD) were associated with
American Indian 3 HAM-D (Hamilton BDD symptom
(4.6) Rating Scale for severity.
Asian 2 (3.1) Depression
Alaskan Native 1 (1.5) NEO-PI-R (Self-report
measure)
Greenberg N: 19 BDD Gender Structured Clinical BDD participants spent X
et al. participants 12/19 BDD female Interview for DSM-IV more time attending
(2014). and 20 (63%); 14/20 HC (SCID) to their least
healthy (70%) Yale-Brown attractive feature.
controls Age Obsessive- and slightly more
Mean age BDD 28.6 Compulsive Scale time focused on the
(11.4)/Mean age HC modified for BDD unattractive part of
33.3 (13.7) (BDD-YBOCS) the control face,
Race/Ethnicity BDD Data Form suggesting global
American Indian/ Brown Assessment of scrutinizing
Alaska Native BDD 1 Beliefs Scale (BABS) tendencies.
(5%); HC: 0(0%) Beck Depression
Asian BDD 2 (11%); Inventory (BDI-II)
HC 4 (20%) BDD Symptom Scale
African American BDD (BDD-SS)
2 (11%); HC 1 (5%) Subjective Unites of
White BDD 18 (95%); Distress Scale (SUDS)
HC 15 (75%) Facial Attractiveness
Mixed Race BDD 3 Scale (FAS)
(16%); HC 0(0) Eye Tracking
Measurement
Greenberg N = 20 BDD/20 Gender Structured Clinical Results revealed a set- X
et al. Healthy Female: HC 14 (70%)/ Interview for DSM-IV shifting deficit
(2018). Controls BDD 12 (60%) (SCID) among BDD
(HC) Male HC 6 (30%)/BDD Yale-Brown participants
8 (40%) Obsessive- compared to healthy
Age: Compulsive Scale controls. Participants
HC 31.65 (13.04) modified for BDD diagnosed with BDD
BDD 28.55 (11.06) (BDD-YBOCS) exhibited deficits in
Race/Ethnicity Brown Assessment of visuospatial
White HC 15 (75%)/ Beliefs Scale (BABS) organization.
BDD 19 (95%) Beck Depression suggesting
African American HC Inventory (BDI-II) neurocognitive
1 (5%)/BDD 2 (10%) CANTAB Intra-Extra deficits as potential
Asian HC 4 (20%)/ Dimensional Set Shift markers of clinical
BDD 2 (10%) (IED) features, including
American Indian HC 0 Rey-Osterrieth delusionality.
(0%)/BDD 1 (5%) Complex Figure Test
(ROCF)
(Continued)
 JOURNAL OF HUMAN BEHAVIOR IN THE SOCIAL ENVIRONMENT 1037

Table 2. (Continued).
Risk
Participant Proximal.
Authors N Characteristics Measures Key Findings Distal
Guzman and N = 1370 Gender Body Dissatisfaction 12 Boys and girls who, X
Nishina adolescents 55% female item scale during early high
(2013). 45% male Perceived pubertal school, perceived
Age: not reported timing relative to themselves to be late
(longitudinal study) peers relative to peers were
Race/Ethnicity Actual pubertal at risk for body
48.2% Latino timing dissatisfaction across
20.2% African the high school years.
American For boys who were
11. 3% Asian/Pacific late in pubertal
Islander development body
9/6% White/ dissatisfaction
Caucasian decreased over time.
9.6% multiethnic However, body
dissatisfaction
persisted for girls,
who see themselves
as late.
Kimber et al. N = 10962 Gender: 49.6% female/ Body Image Distortion First generation X
(2015). 50.4% male (BMI and Self-report) immigrant females
Age: mean 11 to Immigrant were significantly
19 years, with the Generational Status more likely than 3rd
average age of the (Self-report) generation-or-later
sample being Neighborhood adolescents to
15.9 years Concentration of experience body
Race/Ethnicity: (f Immigrants (Census) image distortion.
Hispanic. 12.5 Body Dissatisfaction
Non-Hispanic Black/ (Self report of active
African American 15.1 efforts for weight
Non-Hispanic change)
American Indian 2.2 Center for
Non-Hispanic Asian Epidemiologic
23.7 Studies Depression
Non-Hispanic other Scale
1.1
Non-Hispanic White
65.4
Klimeck et al. N = 180 All mal Muscle Dysmorphic Muscularity and X
(2018). Mean Age 19.6 (2.56) Disorder Inventory thinness
Race/Ethnicity: (MDDI) internalization were
White 99 (55%) Eating Disorder independently
Asian 41 (22.8%) Examination- positively related to
Black/African Questionnaire (EDE- muscle dysmorphia
American 5 (2.8%) Q) symptoms.
Native American 4 Sociocultural
(2.2%) Attitudes Toward
Other 27 (15%) Appearance
Questionnaire-
4-R (SATAQ-4)
Neziroglu N 100 (25 men Gender No formal measures Significantly higher X
et al. OCD/25 50 women (interview) levels of emotional
(2006). women 50 men and sexual abuse
OCD/25 Age were found in the
men BDD/ BDD 31.02 (10.69) BDD sample versus
25 women 34.88 (11.58) the OCD sample. No
BDD) Race/Ethnicity: significant differences
Not reported were found in
physical abuse.
(Continued)
1038 G. MALLINGER

Table 2. (Continued).
Risk
Participant Proximal.
Authors N Characteristics Measures Key Findings Distal
Nierenberg N = 350 Gender: Hamilton Rating Scale Those with BDD had an X
et al. 192 females for Depression earlier age of onset of
(2002). 158 males (HAMD-17) depression and were
Age 39.7 (± Clinical Global more likely to present
10.5 years) Impression (CGI) with atypical
Race/Ethnicity: Not Social Adjustment depression. Subjects
reported Scale-Self-Report with BDD also had
Version (SAS-SR) higher rates of social
Kellner Symptom phobia, eating
Questionnaire disorders, and
Rathus Assertiveness somatoform
Scale disorders but not
OCD. In addition,
clients with BDD had
higher rates of
avoidant, histrionic,
and dependent
personality disorders.
Patton et al. N = 321 Not reported Parental Bonding Media susceptibility was X
(2014). Instrument (PBI) positively linked to
Experiences in Close body image
Relationships Scale dissatisfaction.
(ECR) Further, adverse
Sociocultural parent—child
Attitudes Toward relationships,
Appearance mediated by
Questionnaire attachment anxiety
(SATAQ-3) and susceptibility to
Body Shape sociocultural
Questionnaire (BSQ) pressures, were
BMI related to body
Religiosity (one item) dissatisfaction.
Walker et al. N = 550 Male 550 Muscle Dysphoric Body checking X
(2009). Mean age 18.98 Disorder Inventory (including
(SD = 1.59) (MMDI) comparison to
Race/Ethnicity: Beck Depression others) uniquely
Caucasian 378 Inventory (BDI-II) explained the
(68.9%) Positive and Negative greatest proportion
African American 42 Affect Schedule of variance in muscle
(8.7%) (PANAS) dysmorphia.
Asian 32 (5.8%) Male Body Checking
Hispanic 1 (.2%) Questionnaire
Native American (1 (MBCQ)
(.2%) Eating Disorder
Pacific Islander (22 Examination
(4%) Questionnaire (EDE-
Multi-racial 22 (4.0%) Q)
(Continued)
 JOURNAL OF HUMAN BEHAVIOR IN THE SOCIAL ENVIRONMENT 1039

Table 2. (Continued).
Risk
Participant Proximal.
Authors N Characteristics Measures Key Findings Distal
Weingarden, N = 165 Gender: 92.1% female BDDQ Of those attributing X
Curley Age:29.42 (10.13) Self-Report BDD development of BDD
et al. Race: Y-BOCS symptoms to
(2016). Caucasian 83.6% BDD Trigger Event a triggering event,
Hispanic 6.1% Quality of Life bullying was most
Asian 3% Enjoyment and common. Further,
Other: 7.3% Satisfaction compared to those
Questionnaire-Short who ascribed their
Form(Q-LES-Q-SF) BDD development to
Depression Anxiety another type of
and Stress Scale-21 triggering event,
(DASS-21) participants
Sheehan Disability identifying bullying
Scale (SDS) had poorer
Multidimensional psychosocial
Scale of Perceived outcomes (i.e.,
Social Support perceived social
(MSPSS) support, depression
severity, functional
impairment, quality
of life).
Weingarden N = 184 Gender 92.4% female BDDQ Body shame and X
et al. Age 29.68 (10.14) Body Dysmorphic general shame
(2017). Race/Ethnicity: Disorder Symptom significantly
80.4% Caucasian Scale (BDD-SS) predicted body
2.7% African Test of Self-Conscious dysmorphic
American Affect-4 (TOSCA-4) cognitions; however,
6.0% Asian Body-Focused Shame only body shame
6.5% Hispanic and Guilt Scale- significantly
4.3% Another Race Shame Subscale (BF- predicted severity of
SG) BDD symptoms.
Self-Report Yale-
Brown Obsessive-
Compulsive Scale-
Modified for BDD
(BDD-YBOCS)
Depression Anxiety
and Stress Scale-21
(DASS-21)
Suicide Behaviors
Questionnaire-
Revised (SBQ-R)
Sheehan Disability
Scale (SDS)

Proximal
Of the reviewed studies, seven of the 15 (46.7%) examined the proximal influences of the
diagnosis of BDD and the severity of symptoms. One study (6.6%) investigated both
proximal and distal correlates. These studies assessed cognitive/perceptual and/or emo­
tional associations. One study found significant deficits in executive functioning in those
diagnosed with BDD compared to a group of healthy controls (Blum et al., 2018).
Greenberg et al. (2014) found participants diagnosed with BDD not only focused on their
own unattractive features but also spent more time attending to the least attractive features
of the control face, concluding this attentional bias indicated cognitive and visual
1040 G. MALLINGER

processing issues. Other research revealed difficulties in visuospatial organization, also

suggestive of neurocognitive deficiencies (Greenberg et al., 2018).
The remaining studies focused on emotional factors associated with BDD. Nierenberg
et al. (2002) found those meeting the diagnostic criteria for BDD had an earlier onset of
depression and were significantly more likely to present with atypical depression than their
counterparts presenting with major depression. In addition, those with BDD had higher
rates of social phobia and were more significantly more likely to meet the criteria for
avoidant, histrionic, and dependent personality disorders. Similarly, Fang et al. (2019)
found a correlation with personality disorders and BDD. Neuroticism and low levels of
extroversion were also found to be associated with the severity of BDD symptoms.
According to Weingarden et al. (2017), body shame and general shame were found to
significantly predict BDD, with only body shame influencing the severity of symptoms.
Cafri et al. (2006) reported negative affect (proximal), media influence, and participation in
power sports (distal) as unique predictors in the development of muscular dysphoria.

Distal
Seven of the 15 studies (46.7%) included in this review examined the distal influences of
BDD and symptom severity. Neziroglu et al. (2006) found significantly greater levels of
sexual and emotional abuse in the group of those with BDD than in the comparison group
of those diagnosed with OCD. Similarly, Buhlmann et al. (2012) reported individuals with
BDD significantly experienced more traumatic events, including childhood sexual and
physical abuse, than the comparison group. Weingarden et al. (2017) also examined
linkages between trauma and the onset of BDD and found bullying to be the most common
triggering event. Further, they reported those who identified bullying as the single pre­
cipitating event, had significantly poorer psychosocial outcomes.
The remaining studies examined socio-cultural influences on the development and
severity of BDD. Guzman and Nishina (2013) reported a relationship between the percep­
tion of late physical development compared to peers with the onset of body dissatisfaction.
Kimber et al. (2015) reported first-generation immigrant female adolescents had an
increased likelihood of body image distortion than those who were third-generation or
later. According to Patton et al. (2014), media susceptibility as well as sensitivity to socio­
cultural pressures was significantly linked to BDD. Similarly, Klimeck et al. (2018) reported
a significant correlation between the internalization of societal values about masculinity and
strength and levels of muscle dysphoria. In another study specific to muscle dysmorphia in
men, Walker et al. (2009) found body checking behaviors, including comparing oneself to
others, were significantly correlated with muscle dysphoria.

Discussion
BDD is a complicated disorder and has attracted increased scholarly attention over the past
two decades; however, a comprehensive review of psychosocial correlates is relatively absent
from the literature. Thus, this work synthesizes empirical research pertaining to individual,
interpersonal, and environmental risks influencing BDD for individuals in the United
States. Although there is no way to conclusively predict an individual’s vulnerability to
this diagnosis, certain proximal and distal factors, singularly and in combination, are
associated with its development, severity, and chronicity. This systematic literature review
 JOURNAL OF HUMAN BEHAVIOR IN THE SOCIAL ENVIRONMENT 1041

identified 15 empirical studies with research-supporting cognitive/perceptual, emotional,

familial, peer, and socio-cultural influences. Understanding these risk factors can assist
social workers with early intervention and protect clients against adverse outcomes.

Critique of reviewed studies

The studies included in this review were rigorously designed. Most had sufficient sample
sizes and used established, valid, and reliable measures to determine variables of interest.
Each of the five comparative studies reported moderate to large effect sizes. In addition, the
control and comparison groups were equal or near equal in terms of size, age, and gender.
A limitation shared by most studies was a lack of racial/ethnic diversity among subjects. In
addition, most of the research reviewed relied on cross-sectional designs, preventing the
ability to infer causation.

Limitations of this study

In an effort to focus on recent quality research, this review was limited to empirical
studies published over the past two decades. Thus, publication bias due to the exclusion of
gray literature, dissertations, conceptual works, and government studies, is a possibility.
The inclusion criteria also required studies to be conducted in the United States. More has
been written about correlates of BDD internationally; however, due to well-documented
cultural influences on body issues, the ability to generalize findings to people diagnosed
with BDD in the United States is uncertain. This review did provide a robust search, with
five distinct databases employed. Further, the categorization of correlates in terms of risk
was intended to provide a guide for practitioners, researchers, and educators about micro,
mezzo, and macro interacting to influence the occurrence, seriousness, and continuing
effects of BDD.

Implications for social work

Notably, none of the 15 articles included in this systematic review was published in social
work journals. The studies were divided equally among psychiatric journals (n = 5), psy­
chology journals (n = 5), and journals specializing in body image/eating disorders (n = 5).
The topic of BDD and related disorders has appeared in the social work literature (see, for
example, Wolrich, 2011), but did not qualify for inclusion into this review.
Although social work researchers have not yet made significant contributions to this
literature, given the profession’s unique emphasis on person in environment, social workers
are well-positioned to be in the forefront of this effort. The opportunity for social work to
use longitudinal designs, where micro, mezzo, and macro factors could be measured, would
have particular utility for examining developmental and lifespan issues. Further research is
also needed to clarify the role of protective mechanisms in moderating the relationship
between the aforementioned risks and resilient outcomes. In addition, increased efforts
should also be made to increase the diversity of research participants.
While the evidence reported in this systematic review was published outside of social
work, practitioners can use this information to identify populations at risk for this disorder.
Many BSW and MSW graduates work in behavioral health and/or health-care settings and
1042 G. MALLINGER

are trained to assist in risk factors of BDD and assessing clients for this disorder. Social
workers play a vital role in helping their interprofessional team members recognize the
complex socio-cultural influences of risk for this population.

Conclusion
This systematic review cataloged the existing research on psychosocial risks related to the
development of BDD. While its findings are not without limitations, the included studies
suggest potential risk factors. Moreover, the results informed areas where additional research
is needed. Researchers should intentionally solicit participation from diverse populations.
Future research on micro, mezzo, and macro associated with the development, severity, and
chronicity of BDD is essential in aiding social workers' development of effective prevention
and targeted intervention efforts leading to resilience among individuals with BDD.

Declaration of interest statement

We have no known conflict of interest to disclose.

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