Body dysmorphic disorder (BDD) is defined by the 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 in 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 that means "bad," or "ugly;" and, morphos, that means "shape," or "form." BDD was previously known as dys-morphophobia.
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, to the extent that patients with these disorders are preoccupied with their overall weight and body shape. For example, an adolescent who thinks that her breasts are too large and wants to have plastic surgery to reduce their size but is otherwise unconcerned about o
Body image—A term that refers to a person's inner 3 picture of his or her outward appearance. It has p two components: perceptions of the appearance C of one's body, and emotional responses to those ^
Comorbidity—Association or presence of two or er 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.
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.
her weight and is eating normally would be diagnosed with BDD, not anorexia or bulimia. As many as 50% of patients diagnosed with BDD undergo plastic surgery to correct their perceived physical defects.
<u Since the publication of DSM-IV in 1994, some psy chiatrists have suggested that a subtype of BDD exists, ™ which they term muscle dysmorphia. Muscle dysmorphia .u is marked by excessive concern with one's muscularity 1L and/or fitness. Persons with muscle dysmorphia spend mo unusual amounts of time working out in gyms or exer-ys cising rather than dieting obsessively or looking into plastic surgery. Although gender stereotypes would sug-od gest that women are more likely to develop BDD while M men are more vulnerable to developing muscle dysmor-phia, surveys indicate that both disorders have approximately equal gender ratios. DSM-IV-TR has additional references regarding body build and excessive weight lifting to DSM-IV s description of BDD to accommodate muscle dysmorphia.
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 individuala 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 late childhood or early adolescence; the average age of patients diagnosed with the disorder is 17. Ironically, even though BDD begins in childhood or adolescence, most research and treatment studies to date have been done on adults aged 35 and older.
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).
Causes and symptoms
The causes of BDD fall into two major categories, neurobiological and psychosocial.
neurobiological causes. 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.
psychosocial causes. 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.
A young person's family of origin also 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.
The central symptom of BDD is excessive concern with a specific facial feature or body part. Research done in the United Kingdom and the United States indicates that the features most likely to be the focus of the patient's attention are (in order of frequency) complexion flaws (acne, blemishes, scars, wrinkles); hair (on the head or the body, too much or too little); and facial features (size, shape, or lack of symmetry). The patient's concerns may, however, involve other body parts, and may shift over time from one feature to another.
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, etc.
• 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; it is reported by 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.
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. Adults with muscle dysmorphia have been known to turn down job promotions in order to have more time to work out in their gym or fitness center. Economic consequences of BDD also include overspending on cosmetics, clothing, or plastic surgery.
As was mentioned earlier, BDD is primarily a disorder of young people. Its true incidence in the general population is unknown; however, it has been diagnosed in 1.9% of nonclinical patients and 12% of psychiatric outpatients. 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. One community study published in 2001 found that 0.7% of women between the ages of 36 and 44 met the criteria for BDD. The disorder appears to be equally common in men and women.
As a result of gaps in research, little is known as of 2002 about the lifetime course of BDD or its prevalence in different ethnic or racial groups. The majority of patients in research studies to date have been Caucasians, but it is not clear whether this reflects racial patterns in the wider society or whether it represents referral bias, in that most study subjects are patients in private psychiatric hospitals. Anecdotal evidence, however, indicates that Asian Americans and African Americans with BDD are more likely to obsess about facial features or skin color that conflict with appearance ideals that dominate the mass media and have been derived from Caucasian people. Information through research done on the history of the American cosmetics industry reveals the startling statistic that African Americans spend three to five times as much money on personal care products as Caucasian o
Americans. In addition, successful African American and y
Asian American models, male as well as female, tend to d s resemble the Caucasian appearance ideal more than they m deviate from it. °
The diagnosis of BDD in children and adolescents is d often made by physicians in family practice because they er 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 suffers from BDD because of frequent requests for repeated or unnecessary procedures. Reported rates of BDD among dermatology and cosmetic surgery patients range between 6% and 15%. 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 may suggest a diagnosis of BDD.
As of 2002, there are no diagnostic questionnaires specifically for BDD, although a semi-structured interview called the BDD Data Form is sometimes used by researchers to collect information about the disorder from patients. The BDD Data 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. The diagnostic questionnaire most frequently used to identify BDD patients is the Structured Clinical Interview for DSM-III-R Disorders, or SCID-II.
There are no brain imaging studies or laboratory tests as of 2002 that can be used to diagnose BDD.
The standard treatment regimen for body dysmor-phic disorder is a combination of medications and psychotherapy. Surgical, dental, or dermatologic treatments have been found to be ineffective.
The medications most frequently prescribed for patients with BDD are the selective serotonin reuptake inhibitors, most commonly fluoxetine (Prozac) or sertraline (Zoloft). Other SSRIs that have been used with this group of patients include fluvoxamine (Luvox) and paroxetine (Paxil). In fact, it is the relatively high rate of positive responses to SSRIs among BDD patients that led to the hypothesis that the disorder has a neurobiological
<u 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
_ u who are being treated for depression with these drugs.
The most effective approach to psychotherapy with ¡y BDD patients is cognitive-behavioral therapy, of o which cognitive restructuring is one component. Since 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 wih cognitive restructuring.
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.
Although no alternative or complementary form of treatment has been recommended specifically for BDD, herbal remedies for depressed feelings, such as St. John's wort, have been reported as helping some BDD patients. Aromatherapy appears to be a useful aid to relaxation techniques as well as a pleasurable physical experience for BDD patients. Yoga has helped some persons with BDD acquire more realistic perceptions of their bodies and to replace obsessions about external appearance with new respect for the inner structure and functioning of their bodies.
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