Blue Sonnet

Body dysmorphic disorder
Specialty	Psychiatry, psychomotor education, clinical psychology

Body dysmorphic disorder (BDD) (previously known as Dysmorphophobia and sometimes referred to as Body dysmorphia) is a psychiatric disorder in which the affected person is excessively concerned about and preoccupied by an imagined or minor defect in their physical features. The sufferer may complain of several specific features or a single feature, or a vague feature or general appearance, causing psychological distress that impairs occupational and/or social functioning, sometimes to the point of complete social isolation. It is estimated that between 1%-2% of the world's population meet all the diagnostic criteria for BDD.

Individuals with very obvious and immediately-noticeable defects should not be diagnosed with BDD, however culture and clinician bias may play a significant part in the subjectivity behind determining what physical appearance is considered 'normal' and in whom the disorder is diagnosed. BDD combines obsessive and compulsive aspects, linking it, among psychologists, to the obsessive-compulsive spectrum disorders. The exact cause or causes of BDD is unknown, but most clinicians believe it to be a complex combination of biological, psychological and environmental factors.

Onset of symptoms generally occurs in adolescence or early adulthood, although cases of BDD onset in children and older adults is not unknown. BDD is often misunderstood to affect mostly women, however research shows that it affects men and women equally. The disorder is linked to significantly diminished quality of life and co-morbid major depressive disorder and social phobia. With a completed-suicide rate more than double than that of major depression, and a suicidal ideation rate of around 80%, BDD is considered a major risk factor for suicide. A person with the disorder may be treated with psychotherapy, medication, or both. Research has shown cognitive behavioural therapy (CBT) and selective serotonin reuptake inhibitors (SSRIs) to be effective in treating BDD. BDD is a chronic illness and symptoms are likely to persist, or worsen, if left untreated.

Overview

The Diagnostic and Statistical Manual of Mental Disorders defines body dysmorphic disorder as a preoccupation with an imagined or minor defect in appearance which causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. The individual's symptoms mustn't be better accounted for by another disorder, for example weight concern is usually more accurately attributed to an eating disorder.

The disorder generally is diagnosed in those who are extremely critical of their physique or self-image even though there may be no noticeable disfigurement or defect, or a minor defect which is not recognised by most people. Most people wish that they could change or improve some aspect of their physical appearance; but people suffering from BDD, generally of normal or even highly attractive 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 about their appearance. They tend to be very secretive and reluctant to seek help because they fear that others will think them vain or because they feel too embarrassed. It has also been suggested that fewer men seek help for the disorder than women.

Ironically, BDD is often misunderstood as a vanity-driven obsession, whereas it is quite the opposite, for people with BDD believe themselves to be irrevocably ugly or defective.

BDD combines obsessive and compulsive aspects, linking it, among psychologists, to the Obsessive-Compulsive spectrum disorders. People with BDD may compulsively look at themselves in the mirror or avoid mirrors, typically think about their appearance for at least one hour a day (and usually more), and in severe cases may drop all social contact and responsibilities as they become a recluse.

A German study has shown that 1–2% of the population meet all the diagnostic criteria of BDD, with a larger percentage showing milder symptoms of the disorder (Psychological Medicine, vol 36, p 877). Chronically low self-esteem is characteristic of those with BDD, because the one's assessment of one's value is so closely linked with one's perception of one's appearance. BDD is diagnosed equally in men and women, and causes chronic social anxiety for its sufferers.[1]

Phillips & Menard (2006) found the completed-suicide rate in patients with BDD was 45 times higher than in the general United States population. This rate is more than double that of those with clinical depression and three times as high as that of those with bipolar disorder. Suicidal ideation is also found in around 80% of people with BDD. There has also been a suggested link between undiagnosed BDD and a higher than average suicide rate among people who have undergone cosmetic surgery.

History

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

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.

Diagnoses

According to the DSM IV, to be diagnosed with BDD, a person must possess the following criteria:

• "Preoccupation with an imagined defect in appearance. If a slight physical anomaly is present, the person's concern is markedly excessive."
• "The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning."
• "The preoccupation is not better accounted for by another mental disorder (e.g., dissatisfaction with body shape and size in Anorexia Nervosa)."

In most cases, BDD is under-diagnosed. In a study of 17 patients with BDD, BDD was noted in only five patient charts, and none of the patients received an official diagnosis of BDD despite the fact that it was present. BDD is often under-diagnosed because the disorder was only recently included in DSM IV, therefore clinician knowledge of the disorder, particularly among general practitioners, is not widespread. Also, BDD is often associated with shame and secrecy, therefore patients often fail to reveal their appearance concerns for fear of appearing vain or superficial. BDD is also often misdiagnosed because its symptoms can mimic that of another psychiatric disorder, such as major depressive disorder or social phobia. and the root of the individual's problems remain unresolved. Many individuals with BDD also possess a poor level of insight and regard their problem as one of a physical nature rather than psychiatric, therefore individuals may seek cosmetic treatment rather than mental health treatment.

Prevalence

Studies show that BDD is common in not only nonclinical settings, but clinical settings, as well. A study was done of 200 people with DSM-IV Body Dysmorphic Disorder. These people were of age 12 or older and were available to be interviewed in person. They were obtained from mental health professionals, advertisements, the subject's friends and relatives, and non-psychiatrist physicians. Fifty-three subjects were receiving medication, 33 were receiving psychotherapy, and 48 were receiving both medication and psychotherapy. The severity of BDD was assessed using the Yale-Brown Obsessive Compulsive Scale modified for BDD, and symptoms were assessed using the Body Dysmorphic Disorder Examination. Both tests were designed specifically to assess BDD. Results showed that BDD occurs in 0.7% - 1.1% of community samples and 2%-13% of nonclinical samples. 13% of psychiatric inpatients had BDD. Studies also found that some of the patients initially diagnosed with OCD had BDD, as well. 53 patients with OCD and 53 patients with BDD were compared in a study. Clinical features, comorbidity, family history, and demographic features were compared between the two groups. Nine of the 62 subjects (14.5%) of those with OCD also had BDD.

Comorbidity

There is a high degree of comorbidity with other psychiatric disorders, often resulting in misdiagnoses by clinicians. Research suggests that around 76% of people with BDD will experience major depressive disorder at some point in their life, significantly higher than the 10%-20% expected in the general population. Around 37% of people with BDD will also experience social phobia and around 32% experience obsessive-compulsive disorder. The most common personality disorders found in individuals with BDD are avoidant personality disorder and dependant personality disorder which conforms to the introverted, shy and neurotic traits usually found in individuals with the disorder.

Eating disorders, such as Anorexia nervosa and Bulimia nervosa, are also sometimes found in people with BDD, usually women, as are trichotillomania, dermatillomania, and sub-type disorders Olfactory Reference Syndrome and muscle dysmorphia. A similar disorder, gender-identity disorder, in which the patient is upset with his or her entire sexual biology, often precipitates BDD-like feelings being directed specifically at external sexually dimorphic features, which are in constant conflict with the patient's internal psychiatric gender. The high rate of comorbidity of BDD in GID patients results in an estimated suicide-attempt rate of 20%; the suicide-attempt rate for patients with only BDD is 15%.

Common symptoms and behaviors

There are many common symptoms and behaviors associated with BDD. Often these symptoms and behaviours are determined by the nature of the BDD sufferer's perceived defect, for example, use of cosmetics is most common in those with a perceived skin defect, therefore many BDD sufferers will only display a few common symptoms and behaviors.

Symptoms

Common symptoms of BDD include:

• Obsessive thoughts about perceived appearance defect.
• Obsessive and compulsive behaviors related to perceived appearance defect (see section below).
• Major depressive disorder symptoms.
• Delusional thoughts and beliefs related to perceived appearance defect.
• Social and family withdrawal, social phobia, loneliness and social isolation.
• Suicidal ideation.
• Anxiety; possible panic attacks.
• Chronic low self-esteem.
• Feeling self-conscious in social environments; thinking that others notice and mock their perceived defect.
• Strong feelings of shame.
• Avoidant personality: avoiding leaving the home, or only leaving the home at certain times, for example, at night.
• Dependant personality: dependence on others, such as a partner, friend or parents.
• Inability to work or an inability to focus at work due to preoccupation with appearance.
• Decreased academic performance (problems maintaining grades, problems with school/college attendance).
• Problems initiating and maintaining relationships (both intimate relationships and friendships).
• Alcohol and/or drug abuse (often an attempt to self-medicate).

Compulsive behaviors

Common compulsive behaviors associated with BDD include:

• 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.
• Attempting to camouflage imagined defect: for example, using cosmetics, wearing baggy clothing, maintaining specific body posture or wearing hats.
• Excessive grooming behaviors: skin-picking, combing hair, plucking eyebrows, shaving, etc.
• Compulsive skin-touching, especially to measure or feel the perceived defect.
• Reassurance-seeking from loved ones.
• Excessive dieting and exercise.
• Comparing appearance/body-parts with that of others, or obsessive viewing of favorite celebrities or models whom the person suffering from BDD wishes to resemble.
• Use of distraction techniques: an attempt to divert attention away from the person's perceived defect, e.g. wearing extravagant clothing or excessive jewelry.
• Compulsive information seeking: reading books, newspaper articles and websites which relates to the person's perceived defect, e.g. hair loss or dieting and exercise.
• Obsession with plastic surgery or dermatology procedures, with little satisfactory results for the patient.
• In extreme cases, patients have attempted to perform plastic surgery on themselves, including liposuction and various implants with disastrous results. Patients have even tried to remove undesired features with a knife or other such tool when the center of the concern is on a point, such as a mole or other such feature in the skin.

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

Common locations of perceived 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%)
• Face size/shape (12%)
• Lips (12%)
• Buttocks (12%)
• Chin (11%)
• Eyebrows (11%)
• Hips (11%)
• Ears (9%)
• Arms/wrists (9%)

• Waist (9%)
• Genitals (8%)
• Cheeks/cheekbones (8%)
• Calves (8%)
• Height (7%)
• Head size/shape (6%)
• Forehead (6%)
• Feet (6%)
• Hands (6%)
• Jaw (6%)
• Mouth (6%)
• Back (6%)
• Fingers (5%)
• Neck (5%)
• Shoulders (3%)
• Knees (3%)
• Toes (3%)
• Ankles (2%)
• Facial muscles (1%)

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

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

Development

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. 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. Some of the theories regarding BDD's cause are summarized below:

Biological/genetic

• 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. Serotonin is thought to have a role in regulating anxiety, though it is also thought to be involved in such processes as sleep and memory function. This neurotransmitter travels from one nerve cell to the next via synapses. In order to send chemical messages, serotonin must bind to the receptor sites located on the neighboring nerve cell. It is hypothesized that BDD sufferers may have blocked or damaged receptor sites that prevent serotonin from functioning to its full potential. This theory is supported by the fact that many BDD patients respond positively to selective serotonin reuptake inhibitors (SSRIs) - a class of antidepressant medications that allow for more serotonin to be readily available to other nerve cells. There are cases, however, of patient's BDD symptoms worsening from SSRI use. Imbalance of other neurotransmitters, such as Dopamine and Gamma-aminobutyric acid, have also been proposed as contributory factors in the development of BBD.

• Genetic predisposition: It has been suggested that certain genes may make an individual more predisposed to developing BDD. This theory is supported by the fact that approximately 20% of people with BDD have at least one first-degree relative, such as a parent, child or sibling, who also has the disorder. It is not clear, however, whether this is genetic or due to environmental factors (i.e. learned traits rather than inherited genes). Twin studies suggest that the majority, if not all, psychiatric disorders are influenced, at least to some extent, by genetics and neeurobiology, although no such studies have been conducted specifically for BDD.

• Brain regions: A further biological-based hypothesis for the development of BDD is possible abnormalities in certain brain regions. Magnetic resonance imaging (MRI)-based studies found that individuals with BDD may have abnormalities in brain regions, similar to those found in OCD.

• Visual processing: While some believe that BDD is caused by an individual's distored perception of their actual appearance, others have hypothesized that people with BDD actually have a problem processing visual information. This theory is supported by the fact individual's who are treated with SSRI's often report that their defect has gone - that they no longer see it. However, this may be due to a change in the individual's perception, rather than a change in the visual processing itself.

• 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 or another obsessive-compulsive spectrum disorder 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.

Psychological

• Teasing or criticism: It has been suggested that teasing or criticism regarding appearance could play a contributory role in the onset of BDD. While it's unlikely that teasing causes BDD, since the majority of individuals are teased at some point in their life, it may act as a trigger in individuals who are genetically predisposed. Around 60% of people with BDD report frequent or chronic childhood teasing.

• Parenting style: Similarly to teasing, parenting style may contribute to BBD onset, for example, parents of individuals who place excessive emphasis on aesthetic appearance (i.e. that aesthetic appearance is the most important thing in life) or no emphasis at all may act as a trigger in those genetically predisposed.

• Other life experiences: Many other life experiences may also act as triggers to BDD onset, for example, neglect, physical and/or sexual trauma, insecurity and rejection.

Environmental

• Media: It has been theorised that media pressures may contribute to BBD onset, for example glamour models and the implied necessity of aesthetic beauty. BDD, however, occurs in all parts of the world, including isolated areas where access to media mediums is limited or non-existent. Media pressures are therefore an unlikely cause of BDD, however they could act as a trigger in those already genetically predisposed or could worsen existing BDD symptoms.

Personality

Certain personality traits may make someone more susceptable to developing BDD. Personality traits which have been proposed as contributing factors include;

• Perfectionism
• Shyness
• Introversion
• Sensitvity to rejection or criticism
• Unassertiveness
• Avoidant personality
• Neuroticism

Since personality traits among people with BDD vary greatly, it is unlikely that these are the direct cause of BDD. However, like psychological and environmental factors, they may act as triggers in individuals who already have a genetic predisposition to developing the disorder.

The Disabling Effects of BDD

BDD can be anywhere from slightly to severely debilitating. It can make normal employment or family life impossible. Those who are in regular employment or who have family responsibilities would almost certainly find life more productive and satisfying if they did not have the symptoms. The partners and family of sufferers of BDD may also become involved and suffer greatly, sometimes losing their loved one to suicide.

Studies have shown a positive correlation between BDD symptoms and poor quality of life. Quality of life for inidividuals with BDD has also been shown to be poorer than those found in major depressive disorder, dysthymia, obsessive-compulsive disorder, social phobia, panic disorder, premenstrual dysphoric disorder and Post traumatic stress disorder.

Because BDD onset typically occurs in adolescence, an individual's academic performance may be significantly impacted. Depending on the severity of symptoms, an individual may experience great difficulty maintaining grades and attendance or, in severe cases, an individual may drop out of school and therefore not reach the academic level they are capable of. The vast majority of people with BBD (90%) say that their disorder impacts on their academic/occupational functioning, while 99% say that their disorder impacts on their social functioning.

Sufferers of BDD may often find themselves getting almost 'stuck' in moping around. That is to say that sufferers, with such a type of depression, can in some cases appear to take a long time to get everything done. However, this is not actually the case, as it is simply that the BDD sufferers will often just sit or lie down for prolonged periods of time, without being able to actually motivate themselves until it becomes completely necessary to get back up. This can often cause little to get done by sufferers, and they can have little self motivation with anything, including relationships with other people. However, contrary to this, when the action is relevant to the person's image, it is more common for the sufferer to exhibit a fanatic and extreme approach, applying their attention fully to self-grooming/modification.

Prognosis

Many individuals with BDD have repeatedly sought treatment from dermatologists or cosmetic surgeons with little satisfaction before finally accepting psychiatric or psychological help. Plastic surgery on those patients can lead to manifest psychosis, suicide or never ending requests for more surgery. [2][3]. 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.

Treatments

Studies have found that the psychodynamic approach to therapy, traditional talk therapy, has not been proven effective in treating BDD. However, Cognitive Behavior Therapy (CBT) has proven more effective. In a study of 54 patients with BDD who were randomly assigned to Cognitive Behavior Therapy or no treatment, BDD symptoms decreased significantly in those patients undergoing CBT. BDD was eliminated in 82% of cases at post treatment and 77% at follow-up. (8) Due to low levels of serotonin in the brain, another commonly used treatment is SSRI drugs (Selective Serotonin Reuptake Inhibitor). 74 subjects were enrolled in a placebo-controlled study group to evaluate the efficiency of Fluoxetine hydrochloride (Prozac), a SSRI drug. Patients were randomized to receive 12-weeks of double-blind treatment with fluoxetine or the placebo. At the end of 12 weeks, 53% of patients responded to the fluoxetine.

Body Dysmorphic Disorder is a chronic disorder that if left untreated can worsen with time. Without treatment, BDD could last a lifetime. In many cases, as illustrated in The Broken Mirror by Katharine Phillips, the social and professional lives of many patients disintegrates because they are so preoccupied with their appearance.

Notable sufferers

• Uma Thurman
• Michael Jackson

See also

• Anorexia nervosa
• Anxiety disorders
• Body Integrity Identity Disorder
• Body modification
• Bulimia nervosa
• Clinical depression
• Deformity
• Inferiority complex
• Lookism
• Obsessive-compulsive disorder
• Scars
• Schizophrenia
• Social phobia
• Somatization

References

• Wilhelm, S. Feeling Good About the Way You Look. New York: Guilford Press, 2006
• Phillips, K.A. The Broken Mirror: Understanding and Treating Body Dysmorphic Disorder. New York: Oxford University Press, 1996 (Revised and Expanded Edition, 2005)
• Barlow, David H., & Durand, V. Mark. Essentials of Abnormal Psychology. Thomson Learning, Inc., 2006.
• Neziroglu, F.; Roberts, M.; Yayura-Tobias, J.A.A behavioral model for body dysmorphic disorder. Psychiatric Annals, 34 (12): 915-920, 2004.
• Phillips, KA. Body dysmorphic disorder: the distress of imagined ugliness. American Psychiatric Association, 148: 1138-1149, 1991.[4]
• James Claiborn; Cherry Pedrick. (2004). The BDD Workbook. New Harbinger Publications, U.S. Jan 2003
• Phillips, Katherine A. Body dysmorphic disorder: recognizing and treating imagined ugliness. World Psychiatry, 3(1): 12–17.
• Phillips, K.A., & Castle, D.J. Body dysmorphic disorder. In: Castle DJ, Phillips KA., editors. Disorders of Body Image. Hampshire: Wrightson Biomedical; 2002.
• Grant, J.E., Won Kim, S., & Crow, S.J. (2001). Prevalence and clinical features of body dysmorphic disorder in adolescent and adult psychiatric inpatients. J Clin Psychiatry, 62:517–522.
• Phillips K.A., Nierenberg A.A., Brendel G., et al. (1996). Prevalence and clinical features of body dysmorphic disorder in atypical major depression. J Nerv Ment Dis. 184:125–129.
• Perugi G, Akiskal HS, Lattanzi L, et al. (1998). The high prevalence of "soft" bipolar (II) features in atypical depression. Compr Psychiatry, 39:63–71.
• Zimmerman M, Mattia JI. (1998). Body dysmorphic disorder in psychiatric outpatients: recognition, prevalence, comorbidity, demographic, and clinical correlates. Compr Psychiatry, 39:265–270.
• Phillips KA, McElroy SL, Keck PE Jr, et al. (1993). Body dysmorphic disorder: 30 cases of imagined ugliness. Am J Psychiatry, 150:302–308.

Further reading

• Saville, Chris. "The Worried Well." Body Dysmorphic Disorder. Films for the Humanities & Sciences, Princeton, NJ. 1997. Video Archive. 2004.
• Walker, Pamela. "Everything You Need To Know About Body Dysmorphic Disorder." New York: The Rosen Publishing Group, Inc., 1999.
• Phillips, Dr Katharine A. "The Broken Mirror: Understanding and Treating Body Dysmorphic Disorder", Oxford University Press, 1998
• Thomas F. Cash Ph.D., "The Body Image Workbook", New Harbinger Publications, 1997
• Veale, David and Willson, Rob. "Overcoming Body Shame and Body Dysmorphic Disorder": Robinson, (forthcoming mid 2007)
• The BBC documentary "Too Ugly For Love" is available from UK charity The BDD Foundation
• TV documentary by former BDD sufferer John Furse available from Films Of Record (0207 286 0333)

External links

• BDD Central
• Katharine Phillips, MD - The Body Image Program at Butler Hospital/Brown University
• Massachusetts General Hospital/Harvard Medical School, Body Dysmorphic Disorder Clinic and Research Center
• VideoJug - Body dysmorphic disorder Information
• BDD Research at New York City's Mount Sinai School of Medicine
• UCLA Body Dysmorphic Disorder Research
• OCD-UK - Information for BDD and OCD sufferers
• OCD Action UK
• German Body Dysmorphic Disorder Website
• Body dysmorphic disorder: recognizing and treating imagined ugliness
• The BDD Foundation UK Awareness, Information, Support
• UCSD OCD/BDD Research Program