Body dysmorphic disorder and self-esteem: a meta-analysis

Nora Kuck, Lara Cafitz, Paul-Christian Bürkner, Laura Hoppen, Sabine Wilhelm, Ulrike Buhlmann, Nora Kuck, Lara Cafitz, Paul-Christian Bürkner, Laura Hoppen, Sabine Wilhelm, Ulrike Buhlmann

Abstract

Objective: Body dysmorphic disorder (BDD) is associated with low self-esteem. The aim of this meta-analysis was to examine the strength of the cross-sectional relationship between BDD symptom severity and global self-esteem in individuals with BDD, mentally healthy controls, community or student samples, and cosmetic surgery patients. Moreover, the role of depressive symptom severity in this relationship and other moderating factors were investigated.

Methods: A keyword-based literature search was performed to identify studies in which BDD symptoms and global self-esteem were assessed. Random effects meta-analysis of Fisher's z-transformed correlations and partial correlations controlling for the influence of depressive symptom severity was conducted. In addition to meta-analysis of the observed effects, we corrected the individual correlations for variance restrictions to address varying ranges of BDD symptom severity across samples.

Results: Twenty-five studies with a total of 6278 participants were included. A moderately negative relationship between BDD symptom severity and global self-esteem was found (r = -.42, CI = [-.48, -.35] for uncorrected correlations, r = -.45, CI = [-.51, -.39] for artifact-corrected correlations). A meta-analysis of partial correlations revealed that depressive symptom severity could partly account for the aforementioned relationship (pr = -.20, CI = [-.25, -.15] for uncorrected partial correlations, pr = -.23, CI = [-.28, -.17] for artifact-corrected partial correlations). The sample type (e.g., individuals with BDD, mentally healthy controls, or community samples) and diagnosis of BDD appeared to moderate the relationship only before artifact correction of effect sizes, whereas all moderators were non-significant in the meta-analysis of artifact-corrected correlations.

Conclusions: The findings demonstrate that low self-esteem is an important hallmark of BDD beyond the influence of depressive symptoms. It appears that negative evaluation in BDD is not limited to appearance but also extends to other domains of the self. Altogether, our findings emphasize the importance of addressing self-esteem and corresponding core beliefs in prevention and treatment of BDD.

Keywords: Appearance concerns; Body dysmorphic disorder; Body image; Meta-analysis; Self-esteem.

Conflict of interest statement

SW is a presenter for the Massachusetts General Hospital Psychiatry Academy in educational programs supported through independent medical education grants from pharmaceutical companies; she has received royalties from Elsevier Publications, Guilford Publications, New Harbinger Publications, Springer, and Oxford University Press. SW has also received speaking honoraria from various academic institutions and foundations, including the International Obsessive Compulsive Disorder Foundation, Tourette Association of America, and Brattleboro Retreat. In addition, she received payment from the Association for Behavioral and Cognitive Therapies for her role as Associate Editor for the Behavior Therapy journal, as well as from John Wiley & Sons, Inc. for her role as Associate Editor on the journal Depression & Anxiety. SW has also received honorarium from One-Mind for her role in PsyberGuide Scientific Advisory Board. SW has received salary support from Novartis and Telefonica Alpha, Inc. All other authors do not have any competing interests.

Figures

Fig. 1
Fig. 1
PRISMA flow diagram illustrating the process of study selection
Fig. 2
Fig. 2
Forest plot of Fisher’s z-transformed correlations between BDD symptom severity and self-esteem
Fig. 3
Fig. 3
Forest plot of Fisher’s z-transformed correlations between BDD symptom severity and self-esteem (corrected for variance restriction and enhancement of BDD symptom severity)
Fig. 4
Fig. 4
Forest plot of Fisher’s z-transformed partial correlations between BDD symptom severity and self-esteem controlling for depressive symptom severity
Fig. 5
Fig. 5
Forest plot of Fisher’s z-transformed partial correlations between BDD symptom severity and self-esteem controlling for depressive symptom severity (corrected for variance restriction and enhancement of BDD symptom severity)

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