Underlying morbidities associated with BDD, stratified by body system involvement, are depicted in Figure 3. Cardiovascular conditions were the most frequently associated comorbidities, contributing the largest proportion of background diseases among the study participants. This was followed by musculoskeletal, endocrine, and respiratory system disorders, in that order of frequency. The challenge of an ageing population is a growing global issue that has significant effects on healthcare systems. The United Nations has projected that the number of people aged 65 years or older is to double from 703 million in 2019 to over 1.5 billion by 2050, with most residing in low- and middle-income countries (LMICs).[1] The demographic shift toward an ageing population has increased demand for healthcare services.[2,3] The increase may be attributed to the higher prevalence of chronic diseases, multimorbidity, and complex health conditions among older adults. Signs of population ageing are becoming more evident in sub-Saharan Africa, including Nigeria, despite the region's historical reputation for having a predominantly young population.[4] Thus, understanding and addressing health challenges related to ageing has become a priority for healthcare systems in these areas.

Ageing is often associated with physiological changes that can impair multiple organ systems, leading to atypical presentations of diseases and complex clinical syndromes that may not fit conventional diagnostic categories.[5] In older adults, however, symptoms may be nonspecific or may overlap with existing chronic conditions. Functional somatic symptoms such as persistent physical complaints without identifiable organic causes are commonly reported among this population and significantly contribute to the healthcare burden.[5,6] These symptoms may persist and lead to repeated healthcare visits which are often linked to a poor quality of life and psychological distress.

Geriatric syndromes are prevalent clinical conditions among older adults, characterized by various contributing factors and common risk factors, which significantly impact health outcomes.[5,7] Unlike conditions that affect a single disease, geriatric syndromes are often linked to an accumulation of deficits across multiple organ systems..[8] Geriatric syndromes are important because they significantly affect the health of older adults, given their high prevalence in this population. In a study involving 779 American older adults, 82% were found to exhibit one or more geriatric syndromes. Similarly, a study among older adults in China revealed that 90.5% experienced at least one geriatric syndrome, while in Botswana, 79.2% of community-dwelling older adults reported the presence of such syndromes..[5,8,9] Geriatric syndromes lead to disability, reduced quality of life, and increased mortality among older adults. They require comprehensive, interdisciplinary care approaches due to their complex pathophysiology and clinical presentations.

Bodily Distress Disorder (BDD) is a formally recognized diagnostic framework in the International Classification of Diseases, 11th Revision (ICD-11), as a distinct condition. BDD involves a range of persistent physical symptoms, which can include issues related to the cardiopulmonary, gastrointestinal, and musculoskeletal systems, as well as general symptom clusters.[10,11] Bodily Distress Disorder, as a diagnosis, has largely superseded older concepts such as somatization disorder, somatoform disorders, and medically unexplained symptoms.

Research has shown that BDD is associated with increased healthcare utilization, higher healthcare costs, a reduced quality of life, and psychological distress, including anxiety and depression, along with functional impairment.[12–14] Notably, older adults represent a significant proportion of those affected by functional somatic syndromes like BDD; however, data specific to this age group remain limited.

Despite the inclusion of various conditions under the category of geriatric syndromes, functional somatic symptoms and body dysmorphic disorder (BDD) remain under-recognized in this context. BDD, with its multifactorial presentation and association with chronic diseases, significantly contributes to healthcare utilization and shares key features characteristic of geriatric syndromes. Research from high-income countries indicates that BDD is frequently observed among older adults with multiple chronic conditions.[15] However, there is a lack of research on its recognition and management as a geriatric syndrome, especially in low- and middle-income countries (LMICs) where functional and psychosocial assessment is preferrable to exhaustive investigations in a low resource setting.. This gap in understanding has practical implications, as unrecognized BDD can lead to unnecessary investigations, polypharmacy, increased healthcare costs, and psychological distress for affected individuals.

The World Health Organization's Sustainable Development Goal 3 aims to ensure healthy lives and promote well-being for people of all ages. This goal includes addressing mental health issues and non-communicable diseases. Recognizing Body Distress Disorder (BDD) as a geriatric syndrome supports this global agenda by facilitating early identification, proper management, and integration into comprehensive geriatric care models. In resource-limited settings such as Nigeria, this recognition can enhance clinical awareness and improve resource allocation for older adults who experience persistent somatic symptoms.

This study aims to explore Bodily Distress Disorder (BDD) among older adults attending a geriatric clinic in Nigeria. It proposes recognizing BDD as a geriatric syndrome due to its clinical characteristics, association with multiple health issues, and its continuous impact on healthcare utilization throughout the year. By emphasizing the burden and clinical significance of BDD, this research intends to encourage further investigation and inform healthcare policy regarding the management of older adults in low- and middle-income countries (LMICs).

Study Design and Setting

This study utilized a retrospective descriptive design conducted at the Geriatric Clinic of Ekiti State University Teaching Hospital (EKSUTH) in Ado-Ekiti, located in southwest Nigeria. EKSUTH is a tertiary healthcare institution affiliated with the College of Medicine at Ekiti State University, providing specialized care to residents of Ekiti State as well as referral services to the neighbouring states of Osun, Ondo, Kwara, and Kogi. The Geriatric Clinic focuses on the evaluation and management of individuals aged 65 and older, making it an ideal setting for assessing health service utilization among older adults.

Study Population

The study population consisted of older adults aged 65 years and above who visited the elderly care clinic between January 2022 and December 2024. Patients included in the study were diagnosed with Bodily Distress Disorder (BDD), somatization disorder, or functional somatic syndrome, as documented in their clinical records. Those diagnosed only with hypochondriacal disorder were excluded to maintain diagnostic consistency with the ICD-11 criteria for BDD.

Case Definition

In recognition of the transitional period in diagnostic adoption from ICD-10 to ICD-11, this study included patients with documented diagnoses of Body Dysmorphic Disorder (BDD), somatization disorder, or functional somatic disorder. For the purposes of this study, all cases were collectively classified as BDD, in line with the ICD-11's conceptualization, which includes somatoform and somatization disorders under BDD. Inclusion was limited to patients with persistent functional somatic symptoms that fell within one or more of the following symptom domains: cardiopulmonary, gastrointestinal, musculoskeletal, or generalized symptoms, as described in the ICD-11 symptom cluster.

Data Collection

A structured data extraction form, known as a proforma, was developed to systematically gather relevant clinical information from patients' medical records. The data collected included the patient's age at presentation, sex, the date and month of their clinic visit, and the documented diagnosis, such as BDD or its equivalent. Additionally, underlying comorbidities were categorized by organ system, including areas like cardiovascular, musculoskeletal, endocrine, and respiratory. All diagnoses and comorbidities were extracted exactly as recorded by the attending physicians, and this extraction process was carried out by trained medical personnel to ensure consistency throughout the data collection.

In the data analysis phase, the extracted data were compiled into Microsoft Excel for thorough examination using descriptive statistics. Categorical variables such as age groups, sex distribution, and comorbidities were summarized in terms of frequencies and percentages, allowing for a clear understanding of the demographic characteristics of the BDD cases. For continuous variables, including monthly presentation counts, data were visualized through plots to highlight temporal trends across the study period. The findings were then presented in both tabular and graphical formats, specifically including a table illustrating age distribution across the study years and another one showing the relationship between the number of comorbidity and the burden of the disease, a figure depicting the sex distribution of patients, another figure showing the monthly distribution of BDD diagnoses, and a further figure that outlined the distribution of comorbidities by body system.

Ethical Considerations

Ethical approval for the study was obtained from the Ethics and Research Committee of Ekiti State University Teaching Hospital (EKSUTH) under protocol number EKSUTH/A67/2025/07/084. Strict confidentiality was maintained throughout the study. Patient identifiers were excluded during data extraction to preserve anonymity. As a retrospective chart review, the risk of harm to participants was minimal.

A total of 185 older adults (aged 65 years and above) were diagnosed with Bodily Distress Disorder (BDD) over the three-year study period (2022–2024) at the elderly care clinic. The annual case distribution was 64 cases in 2022, 49 in 2023, and 72 in 2024.

Age Distribution

Across the three years, the majority of patients consistently fell within the 65–74 years age bracket, accounting for 62.5%, 63.3%, and 58.3% of the cases in 2022, 2023, and 2024, respectively (Table 1). Individuals aged 75–84 years comprised 25.0%, 28.6%, and 30.6% of annual cases in the same years. The oldest age group (85–94 years) accounted for a smaller proportion of cases (12.5%, 8.1%, and 11.1% respectively), while no cases were recorded among individuals aged 95 years or older throughout the study period.

Sex Distribution

There was a notable female predominance in the study population. As illustrated in Figure 1, females accounted for approximately two-thirds of the total cases over the three years, yielding an overall male-to-female ratio of 1:2.2.

Monthly Pattern

Analysis of monthly patterns, presented in Figure 2, showed that BDD diagnoses occurred throughout the year without consistent monthly trends or seasonal preponderance. While fluctuations were observed in the number of cases from month to month, no single month or season demonstrated a sustained peak in BDD diagnoses over the study period.

Distribution of Background Morbidity by Body System

Cardiovascular conditions were the most frequently associated comorbidities, contributing the largest proportion of background diseases among the study participants. This was followed by musculoskeletal, endocrine, and respiratory system disorders, in that order of frequency. (Figure 3)

Distribution of subjects based on the number of morbidity and burden of the

Relationship between the number of comorbidity and the burden of the disease is shown in Table 2. It demonstrates a general increasing burden of BDD with increasing numbers of morbidity

Overall, the findings indicate that BDD affects predominantly younger older adults (65–74 years), with a higher burden among females, a year-round presentation pattern, and a broad association with multisystem morbidities, particularly cardiovascular diseases.

Tables and Figures

Table 1: Age distribution of subjects

Figure 1: Sex distribution of Subjects

Figure 2: Monthly distribution of the disease burden over the study period

Figure 3: Distribution of Background Morbidity by Body System

Table 2: Distribution of subjects based on the number of morbidity and burden of the disease

X² = 3.49;   df = 6; P = 0.7

This study examined the burden and clinical characteristics of Bodily Distress Disorder (BDD) among older adults visiting a tertiary care elderly clinic in Nigeria. It suggests that BDD may be classified as a geriatric syndrome. The findings indicate that BDD leads to significant year-round utilization of healthcare services, particularly among younger older adults aged 65 to 74 years. The disorder shows a notable female predominance and is widely associated with various comorbidities, especially cardiovascular conditions.

Globally, population ageing is reshaping healthcare priorities, especially in low- and middle-income countries (LMICs) such as Nigeria, where improvements in healthcare access are steadily increasing life expectancy. As individuals age, their clinical presentations often differ from traditional textbook patterns due to multisystem physiological changes.[16] Our findings reflected this reality, showing that persistent, non-specific somatic symptoms were significant reasons for repeated clinical visits among older adults, complicating diagnostic and management pathways. These observations align with previous reports highlighting that functional somatic symptoms, although often misunderstood, are common and burdensome among the elderly.[17,18]

Our study reinforces existing evidence that women are disproportionately affected by functional somatic syndromes.[19,20] The observed female predominance, with a male-to-female ratio of 1:2.2, may reflect differences in healthcare-seeking behaviours, coping mechanisms, and possibly a greater tendency for symptom reporting among women. Additionally, this phenomenon may indicate a biological or psychosocial predisposition that requires further investigation

The age distribution within our cohort indicates that Body Distress Disorder (BDD) primarily affects the younger segment of older adults, specifically those aged 65 to 74 years. The younger age preponderance and absence of people above 95 years may be because Nigeria is regarded as a country with relatively young population and low life expectancy.[2,21] The female preponderance may be due to better health utilization among females. Previous study has demonstrated female preponderance among the same population.

This aligns with our data, which did not show any cases of BDD in individuals aged 95 and older. This demographic reality likely impacts both the age distribution of BDD and patterns of healthcare utilization.

Another significant observation from this study was the year-round occurrence of Body Distress Disorder (BDD) presentations, showing no consistent seasonal variations. This finding highlights the chronic and persistent nature of BDD, setting it apart from disorders that are episodic or influenced by environmental factors. Patients with BDD often endure ongoing, non-specific symptoms, leading to repeated visits to healthcare providers and greater consumption of healthcare resources as evident in our monthly distribution pattern.

An important aspect to consider is the wide range of comorbidities observed in patients with Body Distress Disorder (BDD). The most common underlying health issue among these patients is cardiovascular disease, followed by musculoskeletal, endocrine, and respiratory conditions. Also of note is the tendency towards an increasing burden of BDD with increasing number of comorbidities, though not statistically significant. These findings support previous studies that have linked chronic physical illnesses to an increased risk of developing BDD. The relationship between these conditions may be bidirectional; the ongoing physical symptoms can both originate from and exacerbate existing chronic illnesses, creating a complex interaction that complicates diagnosis and management.

The proposal to classify this apparent behavioural condition as a geriatric syndrome arises from several observations. Geriatric syndromes are characterized by their multifactorial origins, their association with declines in multiple systems, and their significant impact on functionality and quality of life. BDD meets these criteria. It frequently occurs in older adults, is linked to various chronic conditions, and contributes to increased healthcare utilization, making it a strong candidate for classification alongside established geriatric syndromes such as frailty, delirium, and falls. Similar to these syndromes, BDD is known to be under-recognized, despite its negative effects on health outcomes and associated healthcare costs.[22,23]

The under-recognition of Body Distress Disorder (BDD) has significant clinical and policy implications. Patients with BDD often undergo extensive diagnostic evaluations, receive fragmented care, and may face stigmatization due to the non-specific nature of their symptoms. Clinicians, especially in low- and middle-income countries (LMICs) such as Nigeria, where resources are limited, may overlook or downplay BDD, and thus viewing it as less important than traditional chronic diseases. However, as highlighted by the World Health Organization's  promoting health and well-being throughout life is essential for achieving the broader goal of healthy ageing, particularly in resource-constrained settings.[24]

Acknowledging Body Distress Disorder (BDD) as a geriatric syndrome could drive significant changes. This acknowledgment would legitimize the condition, promote clinician training, encourage patient-centered approaches, and stimulate research focused on understanding its causes and effective management. BDD and related functional somatic disorders, in high-income countries, are gaining recognition within comprehensive geriatric care frameworks. However, this level of recognition is still limited in low- and middle-income countries (LMICs).

Our findings should be interpreted with certain limitations. As a retrospective study, there is the possibility of diagnostic inconsistencies. This arises from the reliance on physician-documented diagnoses without the enforcement of standardized criteria, which could introduce variability. Even though the ICD-11 has categorized somatoform and somatization disorders of BDD), the adoption of these diagnostic criteria in routine clinical practice may not be prompt, particularly in countries like Nigeria. Furthermore, the single-center design of this study limits its generalizability. Nonetheless, the consistent patterns observed over three consecutive years provide valuable insights into the prevalence and characteristics of BDD among older adults in a Nigerian context.

This study emphasises the significant yet often overlooked burden of Body Distress Disorder (BDD) among older adults in a Nigerian tertiary healthcare setting. Therefore, considering BDD as a geriatric syndrome could enhance the diagnosis, management, and overall quality of life for older adults experiencing persistent functional somatic symptoms.

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