Body Dysmorphic Disorder in Patients With Autism Spectrum Disorder: A Reflection of Increased Local Processing and Self-Focus

“Mr. D” is a 25-year-old single white man who meets DSM-5 criteria for autism spectrum disorder (ASD), along with comorbid attention deficit hyperactivity disorder and a nonverbal learning disability (verbal IQ score, 99; performance IQ score, 79). He was diagnosed with ASD as a child and received early intervention and sensory integration services. He currently lives with his mother, is a college graduate, and is employed part-time. He has been preoccupied with the size, shape, coarseness, and color of his body hair, including hair on his wrists, abdomen, fingers, and eyebrows, for the past decade. He is compelled to monitor the hair’s movement and position and whether or not hairs “stand out” and become observable to others, and this nearly constant preoccupation with body hair and compulsion to check his appearance in the mirror is distracting at work. He reports discomfort with any deviation from his expectations. He describes a heightened sensory sensitivity to movement of his hair and disorganization of the hair pattern, wanting it to be in a certain direction and “just so.” For example, wind blowing his body hair causes a feeling of discomfort. This is associated with a high level of anxiety and feelings of shame and self-consciousness. In an attempt to reduce the anxiety and discomfort, he engages in compulsive grooming behaviors, finding the right way for hairs to sit on each finger, sometimes strategically pulling out hairs for a better overall look. On one occasion, he attempted to impose organization on his eyebrows with selective plucking, but he was not satisfied with the result. He admits that it is “ridiculous,” but the discomfort feels “real.” The compulsions are time-consuming and interfere with his performance of tasks at work, and as a result he has repeatedly been fired from jobs.

“Mr. E” is a 36-year-old man with diagnosed ASD and pectus excavatum, for which he has undergone surgical correction. He graduated from college 5 years ago and is unemployed and lives alone. He has been seen as an outpatient for 7 years. He is preoccupied with the appearance of his nose and chest and is overwhelmed by feelings of self-consciousness. He reports obsessing over his nose and feeling compelled to touch it and feel for the presence of a bump, which he does repeatedly, often leaving marks. He frequently compares his nose and chest to those of other people, and he believes that others think he looks deformed. These symptoms improved only slightly after the surgical repair of his chest, and he still feels too self-conscious to go to the swimming pool, an activity he wishes to be able to do.

While in college, Mr. E reported socializing with friends and studying in groups with others, but he described feeling nervous, overthinking things, and frequently having time management problems. Since graduating from college and moving into his own apartment, he has become increasingly socially isolated. He feels he has “awkward social interactions” and questions his social skills. He performs his instrumental activities of daily living, including laundry and grocery shopping, on his own. He reports spending much of his time on the Internet playing computer games, staying up late at night, and avoiding looking for a job.