Body Dysmorphic Disorder
Body Dysmorphic Disorder
Body dysmorphic disorder (BDD) is defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) (a handbook for mental health professionals) as a condition marked by excessive preoccupation with an imaginary or minor defect in a facial feature or localized part of the body. The diagnostic criteria specify that the condition must be sufficiently severe to cause a decline in the patient’s social, occupational, or educational functioning. The most common cause of this decline is the time lost to obsessing about the “defect.” The DSM-IV-TR assigns BDD to the larger category of somatoform disorders, which are disorders characterized by physical complaints that appear to be medical in origin but that cannot be explained in terms of a physical disease, the results of substance abuse, or by another mental disorder.
Although cases of BDD have been reported in the psychiatric literature from a number of different countries for over a century, the disorder was first defined as a formal diagnostic category by the DSM-III-R in 1987. The word “dysmorphic” comes from two Greek words, dys, which means “bad,” or “ugly;” and, morphos, that means “shape,” or “form.” BDD was previously known as dysmorphophobia.
BDD is characterized by an unusually exaggerated degree of worry or concern about a specific part of the face or body, rather than the general size or shape of the body. It is distinguished from anorexia nervosa and bulimia nervosa because patients with these disorders are preoccupied with their overall weight and body shape. For example, an adolescent who obsesses that her breasts are too large and wants to have plastic surgery to reduce their size but is otherwise unconcerned about her weight and is eating normally might be diagnosed with BDD, but not with anorexia or bulimia. Studies have found that between 40% and 76% of people with BDD seek out nonpsychiatric treatments such as cosmetic surgery or dermatological treatments, and the rates of people with BDD among all cosmetic surgery patients range from 7% to 15%; rates are similar in dermatological practices.
Since the first publication of DSM-IV in 1994, some psychiatrists have suggested that a subtype of BDD exists, which they term muscle dysmorphia. Muscle dysmorphia is marked by excessive concern with one’s muscularity and/or fitness. Persons with muscle dysmorphia spend unusual amounts of time working out in gyms or exercising rather than obsessing about a feature such as the skin or nose. Muscle dysmorphia is more prevalent among males. To accommodate muscle dysmorphia as a classification, the DSM-IV-TR has added references regarding body build and excessive weightlifting to DSM-IV ’s description of BDD.
BDD and muscle dysmorphia can both be described as disorders resulting from the patient’s distorted body image. Body image refers to the mental picture individuals have of their outward appearance, including size, shape, and form. It has two major components: how the people perceive their physical appearance, and how they feel about their body. Significant distortions in self-perception can lead to intense dissatisfaction with one’s body and dysfunctional behaviors aimed at improving one’s appearance. Some patients with BDD are aware that their concerns are excessive; others do not have this degree of insight. About 50% of patients diagnosed with BDD also meet the criteria for a delusional disorder, which is characterized by beliefs that are not based in reality.
The usual age of onset of BDD is adolescence; the average age of patients diagnosed with the disorder is 17.
BDD has a high rate of comorbidity, which means that people diagnosed with the disorder are highly likely to have been diagnosed with another psychiatric disorder, most commonly major depression, social phobia, or obsessive-compulsive disorder (OCD).
The causes of BDD fall into two major categories, neurobiological and psychosocial.
Research indicates that patients diagnosed with BDD have serotonin levels that are lower than normal. Serotonin is a neurotransmitter—a chemical produced by the brain that helps to transmit nerve impulses across the junctions between nerve cells. Low serotonin levels are associated with depression and other mood disorders.
A young person’s family of origin has a powerful influence on his or her vulnerability to BDD. Children whose parents are themselves obsessed with appearance, dieting, and/or bodybuilding, or who are highly critical of their children’s looks, are at greater risk of developing BDD.
An additional factor in some young people is a history of childhood trauma or abuse. Buried feelings about the abuse or traumatic incident emerge in the form of obsession about a part of the face or body. This “reassignment” of emotions from the unacknowledged true cause to another issue is called displacement. For example, an adolescent who frequently felt overwhelmed in childhood by physically abusive parents may develop a preoccupation at the high school level with muscular strength and power.
Another important factor in the development of BDD is the influence of the mass media in developed countries, particularly the role of advertising in spreading images of physically “perfect” men and women. Impressionable children and adolescents absorb the message that anything short of physical perfection is unacceptable. They may then develop distorted perceptions of their own faces and bodies.
The central symptom of BDD is excessive concern with a specific facial feature or body part. The parts of the body most frequently involved are the skin, hair, nose, teeth, breasts, eyes, and even eyebrows, but any feature can be a focus of the obsession.
Other symptoms of body dysmorphic disorder include:
- Ritualistic behavior. Ritualistic behavior refers to actions that the patient performs to manage anxiety and that take up excessive amounts of his or her time. Patients are typically upset if someone or something interferes with or interrupts their ritual. In the context of BDD, ritualistic behaviors may include exercise or makeup routines, assuming specific poses or postures in front of a mirror, or skinpicking.
- Camouflaging the “problem” feature or body part with makeup, hats, or clothing. Camouflaging appears to be the single most common symptom among patients with BDD, occurring in 94%.
- Abnormal behavior around mirrors, car bumpers, large windows, or similar reflecting surfaces. A majority of patients diagnosed with BDD frequently check their appearance in mirrors or spend long periods of time doing so. A minority, however, react in the opposite fashion and avoid mirrors whenever possible.
- Frequent requests for reassurance from others about their appearance.
- Frequently comparing one’s appearance to others.
- Avoiding activities outside the home, including school and social events.
BDD patients have high rates of self-destructive behavior, including performing surgery on themselves at home (liposuction followed by skin stapling, sawing down teeth, and removing facial scars with sandpaper) and attempted or completed suicide. Many are unable to remain in school, form healthy relationships, or keep steady jobs. In one group of 100 patients diagnosed with BDD, 48% had been hospitalized for psychiatric reasons, and 30% had made at least one suicide attempt.
The loss of functioning resulting from BDD can have serious consequences for the patient’s future. Adolescents with BDD often cut school and may be reluctant to participate in sports, join church- or civic-sponsored youth groups, or hold part-time or summer jobs. One study found that 32% of participants had missed work for at least a week in the previous month because of their BDD, while 32% of those still in school had missed classes for a week. Adults with muscle dysmorphia have been known to turn down job promotions to have more time to work out in their gym or fitness center. The economic consequences of BDD also include overspending on cosmetics, clothing, or plastic surgery.
As mentioned earlier, BDD is primarily a disorder of young people. Its true incidence in the general population is unknown; however, among the nonclinical, general population, the rate is between 0.7% and 1.1%, and in the narrower student general population, rates range between 2% and 13%. Among psychiatric patients, rates are around 13%. The DSM-IV-TR gives a range of 5-40% for patients in clinical mental health settings diagnosed with anxiety or depressive disorders to be diagnosed with BDD. There have not been significant interactions between ethnicity and gender identified in the few studies examining these factors and BDD. At least one study has found that there appears to be a heritable aspect to BDD, with a higher rate among families of people who have the disorder than among the general population.
The diagnosis of BDD in children and adolescents is often made by physicians in family practice because they are more likely to have developed long-term relationships of trust with the young people. With adults, it is often specialists in dermatology, cosmetic dentistry, or plastic surgery who may suspect that the patient has BDD because of frequent requests for repeated or unnecessary procedures. The diagnosis is made on the basis of the patient’s history together with the physician’s observations of the patient’s overall mood and conversation patterns. People with BDD often come across to others as generally anxious and worried. In addition, the patient’s dress or clothing styles, attempting to hide the “problem” feature, may suggest a diagnosis of BDD.
Several questionnaires are used for assessing the presence of BDD. Researchers sometimes use a semi-structured interview called the BDD Data Form to collect information about the disorder from patients. This form includes demographic information, information about body areas of concern and the history and course of the illness, and the patient’s history of hospitalization or suicide attempts, if any. Another diagnostic questionnaire frequently used to identify BDD patients is the Structured Clinical Interview for DSM-III-R Disorders, or SCID-II. Other questionnaires also used in assessments are the Yale-Brown Obsessive Compulsive Scale Modified for Body Dysmorphic Disorder and the Body Dysmorphic Disorder Examination.
There are no brain imaging studies or laboratory tests as of 2007 that can be used to diagnose BDD. Some studies using brain imaging have identified some characteristics similar to those seen in obsessive-compulsive disorder, although studies are not in complete agreement on this.
The standard treatment regimen for body dysmorphic disorder is a combination of medications and psychotherapy. Surgical, dental, or dermatologic treatments have been found ineffective and in some cases may exacerbate symptoms. In one study, cosmetic surgeons reported that 40% of their patients with BDD had made legal or physical threats against them.
The medications most frequently prescribed for patients with BDD are the selective serotonin reup-take inhibitors (SSRIs), most commonly fluoxetine (Prozac) or sertraline (Zoloft). Other SSRIs that have been used with this group of patients include fluvoxamine (Luvox) and paroxetine (Paxil ). As of 2006, the only one of these medications that is FDA-approved for use in children is fluoxetine.
The relatively high rate of positive responses to SSRIs among BDD patients led to the hypothesis that the disorder has a neurobiological component related to serotonin levels in the body. An associated finding is that patients with BDD require higher dosages of SSRI medications to be effective than patients who are being treated for depression with these drugs.
The most effective approach to psychotherapy with BDD patients is cognitive-behavioral therapy , of which cognitive restructuring is one component. Because the disorder is related to delusions about one’s appearance, cognitive-oriented therapy that challenges inaccurate self-perceptions is more effective than purely supportive approaches. Relaxation techniques also work well with BDD patients when they are combined with cognitive restructuring.
Body image —A term that refers to a person’s inner picture of his or her outward appearance. It has two components: perceptions of the appearance of one’s body, and emotional responses to those perceptions.
Comorbidity —Association or presence of two or more mental disorders in the same patient. A disorder that is said to have a high degree of comorbidity is likely to occur in patients diagnosed with other disorders that may share or reinforce some of its symptoms.
Delusion —A false belief that is resistant to reason or contrary to actual fact. Common delusions include delusions of persecution, delusions about one’s importance (sometimes called delusions of grandeur), or delusions of being controlled by others. In BDD, the delusion is related to the patient’s perception of his or her body.
Displacement —A psychological process in which feelings originating from one source are expressed outwardly in terms of concern or preoccupation with an issue or problem that the patient considers more acceptable. In some BDD patients, obsession about the body includes displaced feelings, often related to a history of childhood abuse.
Muscle dysmorphia —A subtype of BDD, described as excessive preoccupation with muscularity and bodybuilding to the point of interference with social, educational, or occupational functioning.
Neurotransmitter —A chemical produced by the brain that helps to transmit nerve impulses across the junctions between nerve cells.
Serotonin —A widely distributed neurotransmitter that is found in blood platelets, the lining of the digestive tract, and the brain, and that works in combination with norepinephrine. It causes very powerful contractions of smooth muscle, and is associated with mood, attention, emotions, and sleep. Low levels of serotonin are associated with depression.
Somatoform disorders —A group of psychiatric disorders in the DSM-IV-TR classification that are characterized by external physical symptoms or complaints. BDD is classified as a somatoform disorder.
The DSM-IV-TR notes that the disorder “has a fairly continuous course, with few symptom-free intervals, although the intensity of symptoms may wax and wane over time.”
Given the pervasive influence of the mass media in contemporary Western societies, the best preventive strategy involves challenging those afflicted with the disorder and who consequently have unrealistic images of attractive people. Parents, teachers, primary health care professionals, and other adults who work with young people can point out and discuss the pitfalls of trying to look “perfect.” In addition, parents or other adults can educate themselves about BDD and its symptoms, and pay attention to any warning signs in their children’s dress or behavior. They also can modulate their own behaviors of pointing out or highlighting physical “imperfections” in themselves or in their children because there is a link between parents with such concerns and children with BDD.
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American Academy of Child and Adolescent Psychiatry. 3615 Wisconsin Avenue, NW, Washington, D.C. 20016-3007. Telephone: (202) 966-7300. Fax: (202) 966-2891. <http://www.aacap.org>.
National Institute of Mental Health. 6001 Executive Boulevard, Room 8184, MSC 9663, Bethesda, MD 20892-9663. Telephone: (301) 443-4513. <http://www.nimh.nih.gov>.
Rebecca Frey, PhD
Emily Jane Willingham, PhD