Anxiety and Shame as Risk Factors for Depression, Suicidality, and Functional Impairment in Body Dysmorphic Disorder and Obsessive Compulsive Disorder

Abstract

Body dysmorphic disorder (BDD) and obsessive compulsive disorder (OCD) are associated with elevated rates of comorbid depression, suicide risk, and functional impairment. Despite the severe outcomes associated with these disorders, little research has focused on identifying risk factors for such outcomes in BDD and OCD. Anxiety and shame are negative emotions that are central to both BDD and OCD and that have been linked with these outcomes in other populations. The present study used a quasi-experimental design to compare anxiety and shame as risk factors for depression, suicidality, functional impairment, and days housebound across three groups: individuals with BDD (n = 114), individuals with OCD (n = 114), and healthy controls (HC; n = 133). Clinical groups were recruited online through ads on BDD- and OCD-focused websites. HC participants were recruited through non-mental health websites. Participants completed survey measures online through Qualtrics. Follow-up semi-structured clinician interviews were conducted by phone with a subsample of BDD (n = 9) and OCD (n = 10) participants, to verify diagnoses established with self-report measures. Two MANCOVAs testing for group differences in (1) anxiety and shame and (2) the four outcomes, controlling for covariates, were significant. Levels of anxiety, shame, and all four outcomes were lower in the HC group compared to the BDD and OCD groups. BDD and OCD groups had equivalent levels of shame, but anxiety was higher in the OCD group. BDD and OCD groups also had equivalent levels of depression, suicide risk, and housebound rates, but functional impairment was higher in the OCD group. Path analysis was used to compare associations of anxiety and shame with the four outcomes across groups, beginning with a base model that constrained structural paths across groups. We examined improvement in model fit relative to the base model for a series of comparison models, in which structural paths were freed across groups. Freeing structural paths from emotions to outcomes for the HC group (while keeping BDD and OCD paths constrained) yielded significant improvement in model fit. Overall, paths from anxiety and shame to the four outcomes were weaker (and largely non-significant) in the HC group compared to BDD and OCD. Freeing individual structural paths across BDD and OCD groups revealed that, across BDD and OCD groups, most associations of anxiety and shame with outcomes were equivalent and significant. The single exception was that the association of shame with depression was significantly positive in the BDD group (b = .32), but non-significant in the OCD group (b = .07). Results highlight the potential importance of targeting both anxiety and shame in the treatment of BDD and OCD. Results also demonstrated that many of the associations of anxiety and shame with negative outcomes were similar across BDD and OCD, with the exception of relatively greater influence of shame on depression in those with BDD. This novel information about shared risk factors across BDD and OCD supports the reclassification of the two disorders in the new Obsessive Compulsive Related Disorders category, and emphasizes the importance of looking beyond anxiety as the primary emotion related to these disorders.