The prevalence of body dysmorphic disorder among South African university students

Body dysmorphic disorder (BDD) was previously classified in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision (DSMIV-TR) [1] as a somatoform disorder characterised by a preoccupation with a slight or imagined defect in one’s appearance, leading to clinically significant distress or impairment in functioning. Owing to several issues that have been raised regarding the disorder’s status in DSM-IV-TR, it is currently classified as an obsessive-compulsive-related disorder in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5).[2] BDD is defined in DSM-5[2] as a preoccupation with perceived defects or flaws in physical appearance which present with repetitive behaviours or mental acts as a response to the appearance concerns. The prevalence of BDD is unclear. A large variability in data with the differing samples, methodology and research objectives exists. Some researchers[3] point out that there is a lack of literature examining the prevalence of BDD in student samples and that most studies either include women or gender as their only variables. Consequently, they[3] contributed by including ethnicity and sexual orientation as variables. Existing prevalence studies may be inapplicable to the South African (SA) context because they are predominantly European and American.[4] In studying the prevalence and demographic differences in BDD, high-risk groups can be identified which in turn guide prevention and treatment. [4] Current research reporting on patients visiting dermatologists or plastic surgeons often underestimates true prevalence figures;[5] therefore, examining BDD in clinical samples only distorts true prevalence rates in populations. Clinical studies conducted on psychiatric populations and individuals seeking cosmetic and dermatological treatment found the prevalence of BDD among psychiatric patients to be between 0.8% and 16% of the population.[6,7] Demographic differences among the groups in these studies are unclear; however, available research indicates a higher prevalence rate among females.[6,7] Among cosmetic and dermatological patients, findings indicate that BDD is highly prevalent (up to 33%).[8-10] The prevalence in community samples, however, seems to be lower, from 0.7%[11] to 2.4%,[12] with females showing higher prevalence rates than males.[12] The prevalence of BDD among student populations ranges from 2.3% in Australia,[4] to 5.3% in Germany,[13] 4.8% in Turkey,[5] 4.9% in China[14] and 4.9% at an American university.[3] These researchers reported higher prevalence of BDD among male students. Compared with the general population, these studies suggest that BDD is more prevalent among students. This may be a reflection of differences in methodology, the possibility that prevalence is rising among students or because students are more willing to disclose their BDD. There is also a clear difference in gender between community samples and student samples, with the community studies reporting a consistently higher prevalence among females. Perhaps age is a relevant variable, since students tend to have a younger mean age than participants from community studies. It is possible that BDD affects both genders indiscriminately during the late teens or early twenties and over time begins to affect more women than men. Studies that include a large age range are needed in order to explore this hypothesis. In addition to measuring gender differences in BDD, some studies[3,4] included racial differences in their studies. Bartsch[4] found that The prevalence of body dysmorphic disorder among South African university students

Body dysmorphic disorder (BDD) was previously classified in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision (DSM-IV-TR) [1] as a somatoform disorder characterised by a preoccupation with a slight or imagined defect in one's appearance, leading to clinically significant distress or impairment in functioning.Owing to several issues that have been raised regarding the disorder's status in DSM-IV-TR, it is currently classified as an obsessive-compulsive-related disorder in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5). [2]BDD is defined in DSM-5 [2] as a preoccupation with perceived defects or flaws in physical appearance which present with repetitive behaviours or mental acts as a response to the appearance concerns.
The prevalence of BDD is unclear.A large variability in data with the differing samples, methodology and research objectives exists.Some researchers [3] point out that there is a lack of literature examining the prevalence of BDD in student samples and that most studies either include women or gender as their only variables.Consequently, they [3] contributed by including ethnicity and sexual orientation as variables.Existing prevalence studies may be inapplicable to the South African (SA) context because they are predominantly European and American. [4]n studying the prevalence and demographic differences in BDD, high-risk groups can be identified which in turn guide prevention and treatment. [4]Current research reporting on patients visiting dermatologists or plastic surgeons often underestimates true prevalence figures; [5] therefore, examining BDD in clinical samples only distorts true prevalence rates in populations.Clinical studies conducted on psychiatric populations and individuals seeking cosmetic and dermatological treatment found the prevalence of BDD among psychiatric patients to be between 0.8% and 16% of the population. [6,7]emographic differences among the groups in these studies are unclear; however, available research indicates a higher prevalence rate among females. [6,7]10] The prevalence in community samples, however, seems to be lower, from 0.7% [11] to 2.4%, [12] with females showing higher prevalence rates than males. [12]he prevalence of BDD among student populations ranges from 2.3% in Australia, [4] to 5.3% in Germany, [13] 4.8% in Turkey, [5] 4.9% in China [14] and 4.9% at an American university. [3]These researchers reported higher prevalence of BDD among male students.Compared with the general population, these studies suggest that BDD is more prevalent among students.This may be a reflection of differences in methodology, the possibility that prevalence is rising among students or because students are more willing to disclose their BDD.There is also a clear difference in gender between community samples and student samples, with the community studies reporting a consistently higher prevalence among females.Perhaps age is a relevant variable, since students tend to have a younger mean age than participants from community studies.It is possible that BDD affects both genders indiscriminately during the late teens or early twenties and over time begins to affect more women than men.Studies that include a large age range are needed in order to explore this hypothesis.
In addition to measuring gender differences in BDD, some studies [3,4] included racial differences in their studies.Bartsch [4] found that dysmorphic concern was lower among Asian Australian students than among white Australian students, while Boroughs et al. [3] found a lower level of concern among African American women than white and Latina women.The latter study proceeded to examine differences in sexual orientation as well, indicating that BDD was higher among gay and lesbian students than among heterosexual students.
In summary, some variability in the prevalence of BDD among student populations has been shown in studies across various countries.Furthermore, the inclusion of more variables in the study of prevalence rates and group differences contributed to a more nuanced understanding of BDD beyond gender.Therefore, the core questions of this study are to determine what the prevalence of BDD is within an SA university student sample and to report on any group differences for gender, race and sexual orientation.

Sample
A proportionate stratified random cluster sample of 395 undergraduate students (mean (standard deviation (SD)) age of 20.02 (2.45) years) across nine faculties at an inner-city university participated in the study.In order to ensure optimal representation within the current study, the researchers employed a method which entails that different groups or clusters are drawn at random, with an equal distribution of participation in each academic year.The number of students selected in the sample was proportionally representative of the number of undergraduate students for each year group and faculty at the university.Thus, a number of students from various academic modules at undergraduate level, in proportion to the faculty size, were drawn at random from each of the nine faculties at the university.Permission from the lecturers and informed consent from the students were obtained in written form.Ethical clearance for the study was provided by the Academic Ethics Committee of the Faculty of Humanities, University of Johannesburg.

Data collection
The participants were asked to complete a demographic questionnaire, including items such as age, sex, race, and first year of registration, current academic year and sexual orientation.They were also asked to complete the Body Image Disturbance Questionnaire (BIDQ). [15]The BIDQ consists of seven twopart items on a five-point Likert scale.Three of the total 14 items require open-ended responses.The first two questions assess the level of concern with an appearance feature, the third question assesses the degree of subjective distress, and the rest of the items determine the level of functional impairment in different areas.The norm scale indicated that a raw score of 21 or higher on the BIDQ would be indicative of BDD.High internal consistency was found for the BIDQ, with a Cronbach's alpha of 0.89 -0.90 for women and 0.87 -0.89 for men, as well as a testretest reliability of 0.88. [15]As an adjunct, the researchers included a question to determine whether the appearance feature about which the participant is most concerned is weightrelated.This was done to control for weight concerns as a factor in the prevalence of BDD.

Data analysis
The variables were measured using descriptive statistics.The relationship between continuous variables was determined by calculating Pearson product moment correlations.Relationships between categorical variables (gender, age groups, race, and sexual orientation) and the prevalence of BDD were determined using χ 2 analyses.Independent sample t-tests and analysis of variance (ANOVA) were used to determine group differences with continuous variables.The prevalence of BDD is reported as the percentage of participants with BDD relative to the total population of students who participated in the study.
The largest part of the sample consisted of first-year students (n=256; 64.8%), followed by second-years (n=103, 26.1%) and third-years (n=33, 8.4%).Only four students (1.0%) were in their fourth year (as some undergraduate courses are 4-year courses).Participants' ages ranged between 18 and 23 years of age, with a mean (SD) age of 20.02 (2.45) years.Most of the participants were female (n=235; 59.5%).
The sexual orientation of the participants was predominantly heterosexual (n=375; 94.9%), while 8 (2.0%) described themselves as gay or lesbian and 6 (1.5%) as bisexual.Six (1.5%) responded with 'other' , possibly indicating that they are asexual or that they are uncertain of their sexual orientation.

Prevalence of BDD
While BDD was not found in most of the students (n=350; 88.6%), the prevalence of BDD, presented in Table 1, was reported at 5.1% (n=20).Although 24 students (6.1%) met the cut-off score for BDD on the BDIQ (score >21), they were excluded as their primary concern was limited to weight concerns.Most of the students excluded because of weight concerns were female (n=18; 75.0%).However, more males (n=11; 55.0%) than females (n=9; 45.0%) were found to have BDD.

Students with BDD
Fifty per cent of students (n=10) with BDD were in their first year, while 8 (40.0%) were in second year and 2 (10.0%) were third-year students.This implies that 3.91% of the first years participating in the study had BDD, while 7.77% of second years and 6.06% of third years had BDD.
Although more male students (n=11; 55.0%) were found with BDD than female students, no significant difference in the severity of the BDD was found for gender (males: M=3.58 (0.44); females: M=3.34 (0.11); p=0.234).Similarly, no differences were found in terms of prevalence of BDD across racial groups (p=0.187) or groups with different sexual orientations (p=0.115).