Results suggest that patients with BDD experience high levels of social anxiety. The mean baseline SADS score of 19.8 (SD
= 7.7) is 1.3 SD
units higher than the mean of 9.1 (SD
= 8.0) for the normative sample (n
= 205) reported by the scale authors (Watson & Friend, 1969
), indicating a higher magnitude of avoidance and distress about social interaction in BDD relative to nonclinical samples. Similarly, in Veale et al. (2003)
, 107 participants with BDD scored approximately 1.5 SD
s higher than nonclinical controls on both the Social Phobia Scale and the Social Interaction Anxiety Scale. However, BDD does not appear to notably differ from other clinical samples in terms of social anxiety. The SADS score for our sample is consistent with SADS scores reported in Turner, McCanna, and Beidel (1987)
for agoraphobia without panic (M
= 18.4, SD
= 10.2), generalized anxiety disorder (M
= 20.5, SD
= 7.8), obsessive-compulsive disorder (M
= 20.5, SD
= 8.4), and SP (M
= 22.7, SD
= 7.1). These data indicate that high levels of generalized social anxiety are not specific to SP and are in fact present across a number of disorders, including BDD.
Our findings of an association between BDD severity and social anxiety are consistent with previous studies linking negative body image to social anxiety (Leary & Kowalski, 1995
) and introversion (Archer & Cash, 1985
). That social anxiety in BDD is strongly associated with comorbid AVPD but not related to the presence of comorbid SP is most likely due to both the structure of DSM criteria for these disorders and lack of specificity in the SADS. Since the SADS taps general social inhibition, prominent in AVPD, one would expect a higher magnitude of social anxiety in those with both BDD and AVPD. However, patients with and without comorbid SP differ in the kind, but perhaps not the magnitude, of social anxiety experienced, with the comorbid group experiencing social anxiety independent of appearance concerns. The lack of a hypothesized association between delusionality and social anxiety is likely due to a narrow range of BABS scores, with only 10% of participants in the excellent, good, or fair insight range.
Social anxiety did not improve more with fluoxetine than with placebo treatment and the effect size was small. Participants showed improvement in social anxiety regardless of treatment condition, suggesting the possible therapeutic effect of attending frequent pharmacotherapy visits and interacting with study staff. Social anxiety did improve significantly more in fluoxetine responders than in nonresponders, with a medium to large effect size. It should be noted that, among all participants in the fluoxetine trial, improvement in BDD severity was significantly correlated with improvement in social anxiety. However, it is unclear to what extent improvement in BDD may have led to decreased social anxiety, to what extent fluoxetine may have directly reduced social anxiety in responders, or both.
Our study has several limitations. Power for treatment analyses was limited. Due to our efficacy study’s standard inclusion and exclusion criteria, our sample may not be representative of individuals with BDD in the community or other clinical settings. Also, subjects were recruited from a clinic that specializes in BDD, so the results may not extend to nonspecialty settings. Furthermore, since our sample consisted mostly of women, findings may not generalize to men with BDD. Finally, the generalizability of our findings may be limited by the fact that this was a treatment seeking sample. Because the evaluation and treatment process involves social interaction, individuals with BDD who do not seek treatment may be even more socially avoidant than the current sample.
Because the fluoxetine trial was only 12 weeks, longer treatment studies with follow-up phases are needed to determine whether social anxiety would improve more with fluoxetine than placebo over the longer term. Research comparing the effects of CBT versus pharmacotherapy, and their combination, on social anxiety in BDD is also needed.
It is not clear whether a causal relationship exists between social anxiety and the occurrence or severity of BDD; that is, whether high levels of social anxiety contribute to BDD’s development and maintenance, whether BDD causes high levels of social anxiety, or whether the two covary with some other more primary etiologic factor. The authors’ impression is that for some patients, high levels of social anxiety may contribute to BDD’s onset and may contribute to symptom exacerbation. Consistent with this line of reasoning, Wilhelm et al. (1997)
report preliminary data in which the onset of primary SP in patients with comorbid BDD preceded the onset of BDD by 12.6 years. Conversely, many patients with BDD report that appearance preoccupation itself causes significant secondary social anxiety and avoidance. It is important for clinicians to be aware that patients with BDD have high levels of social anxiety and avoidance and that, in our clinical experience, BDD may for this reason be misdiagnosed as SP or lead to dropout from treatment. Additional studies – in particular, longitudinal studies and studies of pathoetiology – are needed to examine the clinically and theoretically important interface between BDD and the construct of social anxiety.