The present study revealed that the prevalence of BDD in the medical students in the medical college was 5.8% with a male to female ratio of 1.7. The top three reported body foci of concern of the students were: being fat, head hair and skin. When comparing across gender, females were found to be significantly more concerned about being fat whereas male students were found to be significantly more concerned about being thin and about head hair.
Prevalence of BDD
Table
3 compares the point prevalence of BDD in studies done in non-clinical samples. It can be seen that the prevalence of BDD in our sample (5.8%) is higher than that in the three other college student samples: German students (5.3%), American students (4%) and Turkish students (4.8%). These three studies are the most comparable because the sample is a non clinical one (college students) and the students have a similar mean age. However, the samples were ill balanced as per the gender distribution to compare the male to female ratio.
Table 3
Comparison of studies assessing the prevalence of BDD
Bohne A et al. [11] | German college students (n = 133, 73.7% females, mean age = 22) | 5.3% |
Bohne A et al. [12] | American college students (n = 101, 82.2% females, mean age = 21) | 4% |
Cansever A et al. [10] | Turkish college students (n = 420, 100% females, mean age = 19) | 4.8% |
Biby et al. [23] | Undergraduate students (n = 102, 76.5% female) | 13% |
Sarwer et al. [43] | American college students (n = 559, 100% females) | 2.5% |
Taqui A M et al. (present study) | Pakistani medical college students (n = 156, 57.1% females, mean age = 21) | 5.8% |
COMMUNITY/POPULATION BASED SAMPLES
| | |
Otto M et al. [13] | Boston community sample (n = 976, 100% female, age = 36–44) | 0.7% |
Faravelli C et al. [31] | Italian community sample (n = 673, 100% female) | 0.7% |
Rief W et al. [44] | German population based survey (age 14–99) | 1.7% |
The slightly higher prevalence of BDD in our sample could be accounted for by a number of different factors. Medical students might be more conscious about their physical appearance than students in most other fields of study, because of society's high expectations from a doctor in terms of grooming and appearance. An association between BDD and education/occupation in art and design has been shown [
29]. However, it is debatable whether an education in art and design may be a contributory factor to the development of BDD or if patients with BDD tend to have an interest in aesthetics. Similarly, the medical profession could be acting as a contributory factor to the development of BDD.
Alternatively, the higher prevalence of BDD could also reflect cross-cultural differences in the value placed on physical attractiveness and the resulting socio-cultural pressures.
As seen from Table
3, the prevalence of BDD in our sample was much higher than that in community based or population samples (5.8% vs. 0.7–1.7%). One plausible explanation is that since the community samples included a large proportion of people above the age of 30, the lower prevalence (0.7%–1.7%) reflects only those people in whom BDD has persisted into late adulthood.
Gender ratio for prevalence of BDD
The present study showed that the male to female ratio for BDD it was 1.7. Comparable studies on non-clinical samples do not show a consistent ratio. Our value was similar to a community study from the United States (n = 373) which found that BDD was present in 1.2% of men and 1% of women, giving the male to female ratio to be 1.2 [
30]. However, a community study from Florence, Italy (n = 673), revealed that 1.4% of women, but no men, had BDD [
31]. The comparable studies done on college student samples either had predominantly female populations or had too small a sample size to give a conclusive male to female ratio for BDD (See Table
3) [
10‐
12].
In clinical sample populations, the gender ratio has shown great variability. Three studies contained more men than women [
6,
16,
32], three contained more women than men [
15,
33,
34] and two contained nearly equal proportions of men and women [
5,
14,
35]. However, these studies were subject to the bias of convenience sampling and do not reflect the true gender ratio in the community. It can be cautiously concluded that the gender ratio in non-clinical populations is not known and may exhibit variability in different populations. These inconsistent gender ratios in both clinical and community samples highlight the need to examine the prevalence of BDD in women and men in larger epidemiological studies.
Our finding of the male to female ratio being 1.7 for BDD was inconsistent with our hypothesis that more females would have self-reported BDD. One plausible reason could be that in medical school, the primary pressure for increased consciousness of self-appearance is society's high expectations from doctors in terms of appearance. This might overshadow the other factor that physical appearance is a means for evaluation of females in the Pakistani society. Hence, the prevalence of self-reported BDD was not higher in females. It is interesting to note that although more females reported body image dissatisfaction than males (88.8% vs 76.1%), the prevalence of BDD was lower in females.
Gender differences in reported body foci of concern
We found four studies which analyzed gender differences extensively. Three of these studies looked at clinical samples [
14‐
16] and one looked at a non clinical sample [
24]. Cash et al did a study on a young college population in the US. Out of the three studies which looked at clinical samples, two studies were done in the US and one was done in Italy.
The present study revealed that the most frequent foci of concern were being fat (31.4%), head hair (24.4%), skin (20.5%), nose (14.7%) and teeth (14.7%). Collectively, this is consistent with the findings in most studies which say that body shape, skin and facial features are among the most common foci of concern [
14,
15,
25,
35‐
37].
Regarding gender differences, Table
1 and Figure
1 show that females were more concerned about being fat, their skin and teeth. Males were more concerned about being thin, being short and their head hair. However, univariate analysis revealed that females were significantly more concerned about being fat and male students were significantly more concerned about being thin and their head hair.
Our findings were concurrent with those in the study done on the US college population [
24], which revealed that the most frequent foci of concern for both genders were weight/shape related concerns, followed by facial features and muscularity for males and legs/thighs and facial features for females. The US study did not elaborate on the weight/shape concerns as being fat or thin. One notable difference is that in the study a sizable proportion of females expressed legs, thighs and breasts as foci of concern, whereas in our study, these responses accounted for less than 4% and were not listed individually in Table
2. This is not surprising. There is a credible reason for this discrepancy, being the fact that in Pakistan, which is a conservative Muslim country, females expressing concern over the size of legs/thighs and breasts, is considered a taboo subject. Females could be hesitant in reporting these foci of concern even if they were preoccupied with them, resulting in the discrepancy.
Looking at the three studies done on clinical samples, some of this study's findings were consistent with the two studies done in the US [
14,
15]: males were more likely to be concerned with thinning hair and small body built, whereas women were more likely to be preoccupied with their weight. However, it did not confirm the findings that women were more concerned with their hips and excessive body hair. Our findings that males were more concerned about their height, was consistent with the study done in Italy [
16].
In all the four studies, it was seen that males were more likely to be preoccupied with their genitals. However, our study did not confirm this finding. Again, societal taboos could lead to underreporting of this body focus of concern.
On the whole, the gender similarities and differences in reported body foci of concern were similar to previous studies. The only major discrepancies (females focusing more on legs/thighs and breasts and males focusing on genitals, in other studies) are explained by the socio-cultural norms in our country.
It is not surprising to see that our finding of females being more concerned about being fat and males being more concerned about being short/body size and head hair, are reflected by appearance concerns which are commonly displayed in advertisements and media. It is well recognized that the media is portraying a steadily thinning ideal body image for women [
38,
39] and a well-built, muscular body image as an ideal for men [
40,
41]. A high proportion of students (76.1%) in our study reported that they compared their perceived physical "defect" with people on television. This suggests that the media plays a major role in determining the ideal body image which a high proportion of individuals strive to attain.
Symptoms of BDD
Our study showed that the symptoms of BDD were fairly common in our sample. However, the severity of majority of the symptoms was not extreme. Table
2 shows the responses of both male and female students to the questions which addressed BDD symptoms. A large proportion of students (79.5%) had the habit of checking their image in reflective surfaces at least occasionally. Twenty three percent of the students practiced this act very often or extremely often. About 60% of the students tried to camouflage their perceived physical "defect" and 54% had the habit of compulsively touching their physical "defect". It was interesting to see that a large proportion of students (73.1%) measured their physical "defect" against people around them and 76.9% compared their physical "defect" with people in magazines or on television.
On the whole, the severity of symptoms was similar across gender. However, it was found that significantly more females (p value = 0.009) compared their perceived physical "defect" with people on television, than males. 85% of females compared their perceived physical "defect" with people on television compared to 65% of females. It is known that the perceived body image of females is directly affected by advertising and media programmes which emphasize the pursuit of a thin body image [
42].
Limitations
The present study had a number of limitations which merit discussion. The major limitation in our study was the use of a questionnaire which had not been validated in our population. The BIDQ has been validated in an American population. At the time of study, there were no instruments validated for use in our population. In these circumstances, we chose the BIDQ over other instruments because it is the only one which has been designed to assess BDD in college students, a non-clinical population. We believe that the high psychometric properties of the BIDQ would not be much altered even if it was used without a validation study. As mentioned above, with the cut-off of 3, the BIDQ is very sensitive at picking up BDD.
It is known that body image problems are more common in young people when BDD may be less severe. They are more common in women and overlap with sub-clinical eating disorders. The finding that 31.4% of students reported being fat as the focus of concern may be reflecting this. In addition to detecting BDD, the BIDQ can capture body image disorders including eating disorders. To exclude these individuals, the study questionnaire included a question which asked students whether they had been diagnosed with anorexia nervosa or bulimia nervosa. However, a single question screen is unlikely to be very effective. Therefore, the prevalence of BDD in this study might be overestimated or it is possible that some of the students with milder BDD had an eating disorder.
Since our data was based on self report, there was no objective way to know whether the defects perceived by the students who appeared to meet the criteria for BDD, were exaggerated or not. This may affect the reliability of our results. The present study was done on medical students from one institution only and this somewhat restricts the generalization of the results to the whole medical student population in Pakistan. However, our sample is likely to be representative since the enrolled students in the university are from all over Pakistan.
In light of these limitations, the findings of the study must be interpreted in a prudent manner.