14 Body Dysmorphic Disorder

Body Dysmorphic Disorder

Clinical presentation

Body dysmorphic disorder (BDD), once called dysmorphophobia, manifests as an excessive concern with minor or wholly nonexistent defects in physical appearance; patients believe themselves to be unacceptably deformed and unattractive when actually they remain normal in appearance. Patients respond to these beliefs with compulsive behaviors, such as repeatedly combing hair or covering up perceived blemishes, that are unpleasant and difficult to control BDD is often associated with low quality of life and frequently is comorbid with major depressive disorder, substance use disorders, obsessive–compulsive disorder (OCD), and social phobias. Patients often are unaware that effective treatments are available and will hide symptoms because of feelings of shame or guilt. BDD is usually associated with increased suicidal ideation, delusional ideas, and poor or absent insight. The delusional variant of BDD is considered more severe. Both delusional and non-delusional variants present challenges in treatment compliance; many patients seek unnecessary dermatologic, dental, and other cosmetic interventions in hopes of removing their perceived flaws. These procedures typically have poor outcomes and lead to patient distress, often worsening symptoms and leading to patient dissatisfaction and loss of self-esteem. Some patients undergo repeated surgeries without achieving the expected outcome and thus have increased risk for depression and suicide.

In BDD, the individual has obsessions and compulsions, however the focus of these obsessions are with perceived defects or flaws in their physical appearance. A key feature of these obsessions are that they are not observable to others. An individual who has a congenital facial defect or a burn victim who is concerned about their scars are not examples of an individual with BDD. The obsessions related to one’s appearance can run the spectrum from feeling “unattractive” to “looking hideous.” While any part of the body can be a concern for an individual with BDD, the most commonly reported areas are skin- such as acne, wrinkles, skin color, hair-particularly thinning or excessive body hair, or nose- size.

Due to the distressing nature of the obsessions regarding one’s body, individuals with BDD also engage in compulsive behaviors that take up a considerable amount of time in one’s day. For example, one may repeatedly compare their body to other people’s bodies in the general public; repeatedly look at themselves in the mirror; engage in excessive grooming which includes using make-up to modify their appearance. Some individuals with BDD will go as far as having numerous plastic surgeries in attempts to obtain their “perfect” appearance. While most of us are guilty of engaging in some of these behaviors, to meet criteria for BDD, one must spend a considerable amount of time preoccupied with their appearance (i.e on average 3-8 hours a day), as well as display significant impairment in social, occupational, or other areas of functioning.

Muscle Dysmorphia

While muscle dysmorphia is not a formal diagnosis, it is a common type of BDD, particularly within the male population. Muscle dysmorphia refers to the belief that one’s body is too small, or lacks appropriate amount of muscle definition (Ahmed, Cook, Genen & Schwartz, 2014). While severity of BDD between individuals with and without muscle dysmorphia appears to be the same, some studies have found a higher use of substance abuse (i.e. steroid use), poorer quality of life, and an increased reports of suicide attempts in those with muscle dysmorphia (Pope, Pope, Menard, Fay Olivardia, & Philips, 2005).

Epidemiology

The prevalence of BDD in the general population is approximately 2% and is strongly associated with a history of cosmetic surgery and higher rates of suicidal ideation and suicide attempts. Patients who present for cosmetic surgery treatment are also affected by BDD at rates markedly higher than in the general population, ranging from 3 to 53%. Its prevalence is markedly increased in the inpatient psychiatric setting, at approximately 16%. Prevalence in outpatients with OCD, social phobia, and other disorders ranged from 10 to 40%. It is often initially undetected, suggesting the importance of BDD-specific screening practices and their role in achieving better outcomes.

BDD usually develops in adolescence, a time when people usually worry about their appearance the most. However, many people with BDD suffer for years before they look for help. When they do look for help to doctors, people with the problem often say they have other problems, for example, depression, social anxiety, or obsessive-compulsive disorder, but do not say their real problem is with the way they look. Most patients can not be convinced that the problem they have with their body is only ‘imagined’, and that they are seeing a ‘changed’ view of themselves, because people do not know much about BDD, compared to other mental problems, for example OCD or others.

Where on the body the ‘imagined’ problem can be

Dr. Katharine Philips (The Broken Mirror, Katharine A Philips, Oxford University Press, 2005 ed, p56) did research, with more than 500 people with BDD, on the percentage of patients unhappy with the most common parts of the body;

BDD can be extremely distressing for people and can interfere greatly in people’s lives. Friendship, romance, and family relationships can be very hard for a person with BDD, as the unhappiness with the looks of the person takes over their life, so they often do not bother with the other aspects of life as much. Also, the BDD stops the person from making these ‘bonds’ with people, as they always feel scared about the way they look, and therefore find it difficult to be themselves with other people. Because of these very high levels of distress in BDD, people with BDD are at heightened risk of suicidal ideation and suicide attempts (Phillips & Menard, 2006). 

Treatment of Body Dysmorphic Disorder 

Similar to OCD, treatment of BDD typically involves psychotherapy, such as cognitive behavioral therapy (CBT) and antidepressants, such as selective serotonin reuptake inhibitors (SSRIs). CBT for BDD focuses on addressing maladaptive cognitions related to one’s appearance, reducing compulsive behaviors (e.g., reducing mirror-checking, not camouflaging body parts that are the focus of the obsession ), and helping address other comorbid conditions, such as depression.

Key Takeaways

Body dysmorphic disorder (BDD)

A disorder that manifests as an excessive concern with minor or wholly nonexistent defects in physical appearance; patients believe themselves to be unacceptably deformed and unattractive when actually they remain normal in appearance.

“Body Dysmorphic Disorder” is adapted from Abnormal Psychology by Coursehero, used under CC BY-SA: Attribution-ShareAlike.