Deadly disorder: imagined-ugliness illness yields high suicide rate.

The suicide rate among people with a psychiatric disorder that causes them to perceive themselves as ugly is higher than that among people with major depression, says a new report.

Over the course of a 4-year study, 2 of 185 patients with body dysmorphic disorder (BDD) committed suicide. That's twice the suicide rate in severely depressed people and 45 times that expected in a general population of the same age, sex, and geographic characteristics, says a research team led by Katharine Phillips of Butler Hospital in Providence, R.I., in the July American Journal of Psychiatry.

People with BDD form a debilitating obsession with some aspect of their appearance--nose size, scars, or body build, for example. The blemish on which they focus may be a delusion or may go unnoticed by other people. Still, patients with BDD often groom for hours a day, and some undergo cosmetic surgery only to wind up unhappy i with the results.

"The core symptoms of BDD can make people feel very isolated, depressed, alone, unwanted" says Phillips. "Then, it's a small step to 'Life isn't worth living.'" The researchers tracked BDD patients, age 12 and older, who either volunteered for the study or were referred by a physician. Ninety percent of the patients received psychiatric treatment at some point during the study.

Nine of the participants attempted suicide during the study, with a combined total of 30 tries, the researchers report. The rate of suicide attempts in BDD patients was higher than that expected in the general population. The rate of suicidal thoughts also greatly exceeded the norm.

In a group the same size with eating disorders, major depression, or bipolar disorder, the researchers would expect to see fewer than the two completed suicides that they report among their BDD patients.

Previous studies based on patient recollections had also shown elevated rates of suicidal thinking and attempts among BDD patients, and physician reports had suggested increased suicide completion.

The high suicide rate might come from other conditions that are likely to affect people with BDD, says Eric Hollander, chair of psychiatry at the Mount Sinai School of Medicine in New York City. Many BDD patients develop severe social anxiety disorder or depression. As a result, they often become socially isolated, incapable of working at an office, and even homebound.

Moreover, the disorder normally begins during adolescence--already a period of heightened suicide risk for some people, Hollander says.

"Some people have felt BDD is a relatively trivial disorder, and that's really not the ease" he says. "This is a life-threatening illness if untreated."

About 2 percent of the population has BDD, estimates Sabine Wilhelm, director of the BDD Clinic and Research Unit at Massachusetts General Hospital in Boston. However, BDD often goes undetected, Wilhelm says, "because patients don't necessarily reveal it on their own." The link to suicides should motivate clinicians to seek out the disorder early, she says.

Phillips cautions that there's been little research on BDD patients. But she says that the high rate of suicide attempts that she reports is "very in keeping with my clinical experience."