Body dysmorphic disorder

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Chelsea Mae Nobleza, M.D.[2] Alonso Alvarado, M.D. [3]

Synonyms and keywords: BDD

Overview

Body dysmorphic disorder (BDD) is a mental disorder that involves a disturbed body image. It is generally diagnosed in those who are extremely critical of their physique or self-image, despite the fact there may be no noticeable disfigurement or defect. Most people wish they could change or improve some aspect of their physical appearance, but people suffering from BDD, generally considered of normal appearance, believe that they are so unspeakably hideous that they are unable to interact with others or function normally for fear of ridicule and humiliation at their appearance. They tend to be very secretive and reluctant to seek help because they are afraid others will think them vanity|vain or they may feel too embarrassed to do so. Ironically, BDD is often misunderstood as a vanity driven obsession, whereas it is quite the opposite; people with BDD believe themselves to be irrevocably ugly or defective. BDD combines obsessive and compulsive aspects, which links it to the OCD spectrum disorders among psychologists. People with BDD may engage in compulsive mirror checking behaviors or mirror avoidance, typically think about their appearance for more than one hour a day, and in severe cases may drop all social contact and responsibilities as they become homebound. The disorder is linked to an unusually high suicide rate among all mental disorders.

Historical Perspective

BDD was first documented in 1886 by the researcher Morselli, who called the condition simply "Dysmorphophobia". BDD was first recorded/formally recognized in 1997 as a disorder in the DSM; however, in 1987 it was first truly recognized by the American Psychiatric Association.

In his practice, Freud eventually had a patient who would today be diagnosed with the disorder; Russian aristocrat Sergei Pankejeff, nicknamed "The Wolf Man" by Freud himself in order to protect Pankejeff's identity, had a preoccupation with his nose to an extent that greatly limited his functioning.

Causes

An absolute cause of body dysmorphic disorder is unknown. However research shows that a number of factors may be involved and that they can occur in combination, including:

• A chemical imbalance in the brain. An insufficient level of serotonin, one of the brain's neurotransmitters involved in mood and pain, may contribute to body dysmorphic disorder. Although such an imbalance in the brain is unexplained, it may be hereditary.

• Obsessive-compulsive disorder. BDD often occurs with OCD, where the patient uncontrollably practices ritual behaviors that may literally take over their life. A history of, or genetic predisposition to, OCD may make people more susceptible to BDD.

• Generalized anxiety disorder. Body dysmorphic disorder may co-exist with generalized anxiety disorder. This condition involves excessive worrying that disrupts the patient's daily life, often causing exaggerated or unrealistic anxiety about life circumstances, such as a perceived flaw or defect in appearance, as in BDD.

Differential Diagnosis

• Anxiety disorder
• Eating disorders
• Illness anxiety disorder
• Major depressive disorder
• Other obsessive-compulsive disorders
• Psychotic disorders

Epidemiology and Demographics

Prevalence

• In the US, the prevalence of BDD is 2,400 per 100,000 (2.4%) of the overall population, being 2,500 per 100,000 females and 2,200 per 100,000 males.
• Outside of the US, the prevalence of BDD is 1,700-1,800 per 100,000 (1.7%-1.8%) of the overall population.
• The distribution of the patients is as shown below:

• The prevalence among dermatology patients is 9,000-15,000 per 100,000 of the overall population.

• The prevalence among cosmetic surgery patients in the US is 7,000-8,000 per 100,000 patients. The prevalence among cosmetic surgery patients outside the US is 3,000-16,000 per 100,000 of the overall population.
• The prevalence among orthodontia patients is 8,000 per 100,000 of the overall population.
• The prevalence among oral and maxillofacial surgery is 10,000 per 100,000 of the overall population.

According to Dr Katharine Phillips (2004) :

Although large epidemiologic surveys of BDD's prevalence have not been done, studies to date indicate that BDD is relatively common in both nonclinical and clinical settings (Phillips & Castle, 2002). Studies in community samples have reported current rates of 0.7% and 1.1%, and studies in nonclinical student samples have reported rates of 2.2%, 4%, and 13% (Phillips & Castle, 2002). A study in a general inpatient setting found that 13% of patients had BDD (Grant, Won Kim, Crow, 2001). Studies in outpatient settings have reported rates of 8%-37% in patients with OCD, 11%-13% in social phobia, 26% in trichotillomania, 8% in major depression, and 14%-42% in atypical major depression (Phillips & Castle, 2002). In one study of atypical depression, BDD was more than twice as common as OCD (Phillips, Nierenberg, Brendel et al 1996), and in another (Perugi, Akiskal, Lattanzi et al, 1998) it was more common than many other disorders, including OCD, social phobia, simple phobia, generalized anxiety disorder, bulimia nervosa, and substance abuse or dependence. In a dermatology setting, 12% of patients screened positive for BDD, and in cosmetic surgery settings, rates of 6%-15% have been reported (Phillips & Castle, 2002).

BDD is underdiagnosed, however. Two studies of inpatients (Phillips, McElroy, Keck et al, 1993, and Grant, Won Kim, Crow, 2001), as well as studies in general outpatients (Zimmerman & Mattia, 1998) and depressed outpatients (Phillips, Nierenberg, Brendel et al 1996), systematically assessed a series of patients for the presence of BDD and then determined whether clinicians had made the diagnosis in the clinical record. All four studies found that BDD was missed by the clinician in every case in which it was present. Thus, underdiagnosis of BDD appears common.

Gender

The prevalence of BDD is equal in men and women.

Risk Factors

• First-degree relatives of patients with obsessive compulsive disorder (OCD)
• History of childhood abuse

Natural History, Complications, and Prognosis

Natural History

BDD usually develops in adolescence, a time when people are generally most sensitive about their appearance. However, many patients suffer for years before seeking help. When they do seek help through mental health professionals, patients often complain of other symptoms such as depression, social anxiety or obsessive compulsive disorder, but do not reveal their real concern over body image. Most patients cannot be convinced that they have a distorted view of their body image, due to the very limited knowledge of the disorder as compared to OCD or others. Male patients have more risk of developing the obsession around the genitalia and females have higher risk of developing eating disorders associated with the BDD.

Complications

Suicide Risk

• The suicide rates in patients with BDD are high in at all ages, with a higher incidence in adolescent patients.
• Risk factors associated with a completed suicide in patients with BDD are suicide thoughts and previous attempts, association with major depressive syndrome and demographic locations associated with high rates of suicide.
• Phillips & Menard (2006) found the completed suicide rate in patients with BDD to be 45 times higher than in the general US population. This rate is more than double that of those with Clinical depression and three times as high as those with bipolar disorder. There has also been a suggested link between undiagnosed BDD and a higher than average suicide rate among people who have undergone cosmetic surgery.

Functional Consequences of BDD

• Impaired psychosocial development which can range from mild (the patient avoid social situations) to severe (the patient doesn't leave the house).
• The severity of the disorder is usually directly associated with the degree of psychosocial impairment.
• Chronically low self-esteem is characteristic of those with BDD due to the value of oneself being so closely linked with their perceived appearance. BDD causes chronic social anxiety for those suffering from the disorder[4].

Prognosis

Many individuals with BDD have repeatedly sought treatment from dermatologists or cosmetic surgeons with little satisfaction before finally accepting psychiatric or psychological help. Treatment can improve the outcome of the illness for most people. Other patients may function reasonably well for a time and then relapse, while others may remain chronically ill. Research on outcome without therapy is not known but it is thought the symptoms persist unless treated.

Diagnosis

Diagnostic Criteria

DSM-V Diagnostic Criteria for Body Dysmorphic Disorder Body Dysmorphic Disorder

“

The patient is preoccupied with an imagined defect of appearance or is excessively concerned about a slight physical anomaly. AND During the course of the disease the patient develops behaviors such as excessive mirror checking, grooming, seek for reassurance or compare his/her appearance with others. AND This preoccupation causes clinically important distress or impairs work, social or personal functioning. AND Another mental disorder (such as Anorexia Nervosa) does not better explain the preoccupation.

”

Symptoms

• Compulsive mirror checking, glancing in reflective doors, windows and other reflective surfaces.
• Alternatively, an inability to look at one's own reflection or photographs of oneself; often the removal of mirrors from the home.
• Compulsive skin-touching, especially to measure or feel the perceived defect.
• Reassurance-seeking from loved ones.
• Social withdrawal and co-morbid depression.
• Obsessive viewing of favorite celebrities or models the person suffering from BDD may wish to resemble.
• Excessive grooming behaviors: combing hair, plucking eyebrows, shaving, etc.
• Obsession with plastic surgery or multiple plastic surgeries with little satisfactory results for the patient.
• In obscure cases patients have performed plastic surgery on themselves, including liposuction and various implants with disastrous results.

Common Locations of imagined Defects

In research carried out by Dr. Katharine Philips, involving over 500 patients, the percentage of patients concerned with the most common locations were as follows:

• Skin (73%)
• Hair (56%)
• Nose (37%)
• Weight (22%)
• Stomach (22%)
• Breasts/ Chest/ Nipples (21%)
• Eyes (20%)
• Thighs (20%)
• Teeth (20%)
• Legs (Overall) (18%)
• Body Build/ Bone Structure (16%)
• Ugly Face (General) (14%)
• Lips (12%)
• Buttocks (12%)
• Chin (11%)
• Fingers
• Eyebrows (11%)

Source: The Broken Mirror, Katharine A Philips, Oxford University Press, 2005 ed, p56

People with BDD often have more than one area of concern.

Treatment

Typically the psychodynamic approach to therapy does not seem to be effective in battling BDD while in some patients it may even be countereffective.

CBT (Cognitive Behavioral Therapy) coupled with exposure therapy has been shown effective in the treatment of BDD. Low levels or insufficient use of serotonin in the brain has been implicated with the disorder and so SSRI drugs are commonly used, and with some success, in the treatment of Body Dysmorphic Disorder. Drug treatment will sometimes also include the use of an anxiolytic.

BDD tends to be chronic; current information suggests that symptoms do not subside, but rather worsen through time. Indeed in most patients, the symptoms and concerns diversify and social contacts may further deteriorate. As so, treatment should be initiated as early as possible following the diagnoses.

Historical Perspective

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