Body dysmorphic disorder

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Body dysmorphic disorder
Classification and external resources
ICD-10 F45.2
ICD-9 300.7
DiseasesDB 33723
eMedicine med/3124 

Body dysmorphic disorder (BDD) is a mental disorder in which the affected person is excessively concerned about and preoccupied by an imagined or minor defect in his or her 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 important functioning (e.g. occupational or self-care) or social aspects of life.[1]

Individuals with very obvious and immediately-noticable 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.[2] Onset of symptoms generally occurs in adolescence. The disorder is thought to affect both men and women equally and is linked to an unusually high suicide rate among all mental disorders.

Contents

[edit] Overview

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.[3]

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 OCD-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.[4] There has also been a suggested link between undiagnosed BDD and a higher than average suicide rate among people who have undergone cosmetic surgery.[5] 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%.[6][7]

[edit] 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.

[edit] 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)."[8]

[edit] 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. Common symptoms and behaviors 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 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.
  • Social withdrawal and co-morbid depression.
  • Avoiding leaving the home, or only leaving the home at certain times, for example, at night.
  • Inability to work.
  • Inability to focus at work due to preoccupation with appearance.
  • Feeling self-conscious in social environments; thinking that others notice and mock their perceived defect.
  • 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 multiple plastic surgeries, 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

[edit] 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.

[edit] 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. 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.

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.

[edit] 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.

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.

[edit] 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.

[edit] 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.[9] 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.[10]

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.[11]

[edit] 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.[12]

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.[13]

[edit] See also

[edit] References

  1. ^ American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (text revision). Washington, DC: Author
  2. ^ Kress, V.E.W.; Eriksen, K.P.; Rayle, A.D.; & Ford, S.J.W. (2005). The DSM-IV-TR and culture. Considerations for counselors. Journal of counseling and Development, 83(1), 97-104.
  3. ^ Phillips, K. A. (1996). The broken mirror Understanding and treating body dysmorphic disorder. p141 New York: Oxford University Press.
  4. ^ Suicidality in Body Dysmorphic Disorder: A Prospective Study - Phillips and Menard 163 (7): 1280 - Am J Psychiatry
  5. ^ Cosmetic surgery special: When looks can kill - health - 19 October 2006 - New Scientist
  6. ^ Seattle and King County Health - Transgender Health
  7. ^ Katharine A. Phillips, MD Suicidality in Body Dysmorphic Disorder Primary Psychiatry. 2007;14(12):58-66
  8. ^ American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders, 468 Washington, D.C.: Author.
  9. ^ Phillips, K. A., Menard, W., Fay, C., & Weisberg, R. (2006). Demographic characteristics, phenomenology, comorbidity, and family history in 200 individuals with body dysmorphic disorder [Electronic version]. Pyschomatics, 46, 317-325.
  10. ^ Phillips, K. A., Gunderson, C. G., Mallya, G., McElroy, S. L., Carter, W. (1978). Physicians Postgraduate Press: A comparison study of body dysmorphic disorder and obsessive-compulsive disorder. The Journal of Clinical Psychiatry. Retrieved December 10, 2007, from http://archpsyc.highwire.org/cgi/content/56/11/1033
  11. ^ Rosen, J. C. (1995). Cognitive-behavioral body image therapy for body dysmorphic disorder [Electronic version]. Journal of Consulting Psychology, 63, 263-269.
  12. ^ Phillips, K. A., Albertini, R. S., Rasmussen, S. A. (2002). A randomized placebo-controlled trial of fluoxetine in body dysmorphic disorder. Arch Gen Psychiatry. Retrieved December 10, 2007, from the webpage: http://archpsyc.ama-assn.org
  13. ^ Phillips, K. A. (1996). The broken mirror Understanding and treating body dysmorphic disorder. New York: Oxford University Press.
  • 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.[2]
  • 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.

[edit] 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

[edit] External links