Body Dysmorphic Disorder – Introduction
- Body dysmorphic disorder (BDD) is classified as an obsessive-compulsive and related disorder.
- It is characterized by preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear only slight to others, as well as repetitive behaviors (e.g., excessive grooming, mirror checking, skin picking, reassurance seeking) in response to the appearance concerns.
- To qualify for a diagnosis of BDD, the preoccupations must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
- The preoccupations are not better explained by concerns with body fat or weight in a person for whom these symptoms meet diagnostic criteria for an eating disorder.
Synonyms
- Dysmorphophobia
- BDD
ICD-10CM CODE | |
F45.22 | Body dysmorphic disorder |
DSM-5 CODE | |
F45.22 |
Epidemiology & Demographics
- •Currently affects 1.7% to 2.9% of the general population (point prevalence in nationwide epidemiologic studies). 1
- •Prevalence among general cosmetic surgery patients is 13% to 15%. 2
- •Weighted prevalence in rhinoplasty surgery settings is 20%. 2
- •Weighted prevalence among dermatology outpatients is 11% to 13%. 2
- •Slightly higher prevalence among females (but more males than females in general cosmetic surgery, rhinoplasty, and general dermatology settings). 2
- •Onset most commonly in early adolescence (two thirds have onset before age 18). 3
Physical Findings & Clinical Presentation
- •Excessive preoccupation (obsession) with one or more perceived defects in appearance that are not observable or appear only slight to others. Patients believe they look abnormal, ugly, unattractive, or deformed, whereas in reality they look normal. Any part of the body may be a focus of concern; skin (e.g., perceived acne or scarring), hair (e.g., perceived thinning or excessive body or facial hair), and nose (e.g., size or shape) concerns are most common. 3 Muscle dysmorphia is a form of BDD that occurs primarily in men and focuses on excessive concern that one’s body build is too small or is insufficiently muscular. Most patients with BDD are preoccupied with multiple body areas. 3 Concerns with perceived asymmetry of body areas is common.
- •The body areas with which the patient is concerned appear physically normal; if a physical defect is present, it is slight, and the patient’s reaction to it is excessive.
- •Most patients have poor insight (i.e., are mostly convinced) or absent insight (i.e., delusional beliefs; are completely convinced) regarding the accuracy of their beliefs about the appearance of the perceived defects. 3
- •At some point during the course of the disorder, all patients engage in repetitive behaviors such as frequent checking of mirrors or other reflecting surfaces, comparing their appearance with that of other people, excessive grooming, skin picking to try to fix perceived skin flaws, reassurance seeking, taking excessive selfies, or repeatedly measuring or feeling the perceived defect. 3 The intent of these behaviors is to check, try to improve, or gain reassurance about the appearance of the perceived flaws. Nearly all patients attempt to camouflage or hide the perceived defects—e.g., with makeup, a hat, hair, or body position. 3
- •Nearly all experience impairment in psychosocial functioning and quality of life as a result of their appearance concerns; impairment is usually substantial. More severe BDD symptoms are associated with poorer functioning and quality of life. 4
- •Suicidal ideation, suicide attempts, and completed suicide appear common. 3 , 5 , 6 Several studies have found that BDD is characterized by significantly higher levels of suicidality than other psychiatric disorders characterized by high risk for suicidal thoughts and acts. 56 Greater BDD severity is associated with higher risk for suicidal ideation and suicide attempts.
- •Commonly co-occurring mental disorders are major depressive disorder, substance use disorders (including abuse of anabolic androgenic steroids in the muscle dysmorphia form of BDD), social anxiety disorder, obsessive-compulsive disorder (OCD), and personality disorder. 3
What causes Body Dysmorphic Disorder?
- Likely multifactorial, with both genetic and environmental risk factors (e.g., teasing). Has shared genetic vulnerability with obsessive-compulsive disorder plus BDD-specific genetic influences. 7
- Neuropsychological, fMRI, and other studies indicate abnormalities in visual processing consisting of excessive focus on details rather than on larger global and configural elements of visual stimuli (with some similarities to anorexia nervosa). 8
- Cognitive and emotional processing deficits and biases also characterize BDD, which may also play a role in the disorder’s development and/or maintenance. 9
How is this condition diagnosed?
Psychiatric interview: Ask:
- •Are you very worried about your appearance in any way? OR: Are you unhappy with how you look?
- •Does this concern with your appearance preoccupy you? If you add up all the time you spend each day thinking about your appearance, how much time would you estimate it takes (at least an hour a day)?
- •How much distress do your appearance concerns cause you?
- •What effect does this concern have on your life?
- •Is there anything you feel an urge to do over and over again in response to your appearance concerns? (Give examples, such as mirror checking, comparing with others, skin picking to remove perceived skin flaws if skin is a concern.)
- •Determine that the perceived appearance defects are actually nonexistent or only slight.
Differential Diagnosis
- Often undiagnosed because of patient’s reluctance to divulge symptoms due to shame and fear of being misunderstood (e.g., considered vain)
- OCD
- Eating disorder
- Social anxiety disorder
- Major depressive disorder
Workup
- Clinical evaluation focused on BDD symptoms and associated distress and impairment in functioning.
- If the patient is preoccupied with being overweight but is actually normal or nearly normal weight, determine if they have an eating disorder; if they do, the weight preoccupation is considered a symptom of the eating disorder rather than BDD.
- However, if the patient does not have an eating disorder, then the weight concern may count toward a BDD diagnosis. Some patients have both BDD and an eating disorder; comorbidity is common.
TREATMENT
NONPHARMACOLOGIC THERAPY
- •Cognitive behavioral therapy (CBT), with a focus on cognitive restructuring and other cognitive strategies, exposure with behavioral experiments, perceptual retraining, and response (ritual) prevention. Use habit reversal training for skin picking and hair pulling/plucking that is due to BDD. Activity scheduling/behavioral activation may be needed for more depressed patients. CBT must be specifically tailored to BDD’s unique symptoms. 10 , 11
- •Do not try to talk patients out of their concern; it is ineffective.
- •Avoid cosmetic procedures; a majority of patients with BDD receive them, but such treatments do not appear effective for BDD and can make symptoms worse. 12 , 13
- •Dissatisfied patients may sue or even become violent toward the clinician who provided cosmetic treatment. 12 , 13
PHARMACOLOGIC THERAPY
- •Serotonin reuptake inhibitors (SRIs) are medication of choice both acutely and chronically; high doses (similar to those for OCD) are often needed. 14 , 15
- •Other agents (e.g., neuroleptics, tricyclic antidepressants other than clomipramine) do not appear as beneficial as monotherapy. Limited evidence suggests that atypical neuroleptics (perhaps, in particular, aripiprazole), and buspirone may be helpful as SRI augmentation agents. Clinical experience suggests that glutamate modulators such as N-acetylcysteine and memantine, often at higher doses, may also effectively augment SRIs in some cases. 14 , 15
CHRONIC Treatment
- •CBT tailored specifically to BDD is recommended. 11 Treatment with an SRI is recommended if BDD symptoms are moderate to severe, the patient is suicidal because of BDD symptoms, or comorbidity is present that may benefit from an SRI. 14
- •SRI treatment without CBT is also appropriate for some patients. 14
- •A combination of an SRI (with augmenting medication if needed) and CBT for BDD (intensive treatment if needed) is recommended for more severely ill patients. 14
- •Support groups if available
- •More intensive BDD-focused treatment (e.g., residential treatment) if outpatient care is insufficient
Disposition
- •Untreated BDD tends to be chronic and can lead to social isolation; school dropout; loss of employment; major depression; abuse of drugs or alcohol; unnecessary surgery, dermatologic treatment, or other cosmetic treatment; and suicide. 3 , 12 , 13
- •With correct diagnosis and treatment, a majority improve.
PEARLS & CONSIDERATIONS
- •In clinical settings, approximately three quarters have lifetime co-occurring major depressive disorder; suicidal ideation is common. 3
- •Reassurance that the patient looks normal is rarely helpful.
- •Patients often have an unrealistic expectation of improvement with plastic surgery, dermatologic treatment, and other cosmetic procedures; these treatments do not appear to be effective and can worsen BDD symptoms. 12 , 13
- •All patients should be screened and monitored for suicidality.
- •CBT tailored to BDD and SRIs (high doses are often needed) are often effective. 10 , 14 , 15
PATIENT & FAMILY EDUCATION
- •Family support and encouragement of appropriate treatment is important
- •https://bdd.iocdf.org/
References
1.Hartmann A.S., Buhlmann U.: Prevalence and underrecognition of body dysmorphic disorder . In Phillips K.A. (eds): Body dysmorphic disorder: advances in research and clinical practice . 2017. Oxford University Press , New York pp. 49-60.
2.Veale D., et al.: Body dysmorphic disorder in different settings: a systematic review and estimated weighted prevalence . Body Image 2016; 18: pp. 168-186.
3.Phillips K.A., et al.: Demographic characteristics, phenomenology, comorbidity, and family history in 200 individuals with body dysmorphic disorder . Psychosomatics 2005; 46: pp. 317-332.
4.Phillips K.A., et al.: Psychosocial functioning and quality of life in body dysmorphic disorder . Comprehensive Psychiatry 2005; 46: pp. 254-260.
5.Angelakis I., et al.: Suicidality in body dysmorphic disorder (BDD): a systematic review with meta-analysis . Clin Psychol Rev 2016; 49: pp. 55-66.
6.Snorrason I., et al.: Body dysmorphic disorder and major depressive episode have comorbidity- independent associations with suicidality in an acute psychiatric setting . J Affect Disord 2019; 259: pp. 266-270.
7.Monzani B., et al.: The structure of genetic and environmental risk factors for dimensional representations of DSM-5 obsessive-compulsive spectrum disorders . JAMA Psychiatry 2014; 71: pp. 182-189.
8.McCurdy-McKinnon D., Feusner J.D.: Neurobiology of body dysmorphic disorder: heritability/genetics, brain circuitry, and visual processing . In Phillips K.A. (eds): Body Dysmorphic Disorder: Advances in Research and Clinical Practice . 2017. Oxford University Press , New York pp. 253-276.
9.Buhlmann U., Hartmann A.S.: Cognitive and emotional processing in body dysmorphic disorder . In Phillips K.A. (eds): Body dysmorphic disorder: advances in research and clinical practice . 2017. Oxford University Press , New York pp. 285-297.
10.Wilhelm S., et al.: Cognitive-Behavioral Therapy for Body Dysmorphic Disorder: A Treatment Manual . 2013 . Guilford Press , New York
11.Wilhelm S., et al.: Efficacy and posttreatment effects of therapist-delivered cognitive behavioral therapy vs supportive psychotherapy for adults with body dysmorphic disorder: a randomized clinical trial . JAMA Psychiatry 2019; 76: pp. 363-373.
12.Phillips K.A., et al.: Surgical and nonpsychiatric medical treatment of patients with body dysmorphic disorder . Psychosomatics 2001; 42: pp. 504-510.
13.Ishii L.E., et al.: Clinical practice guideline: improving nasal form and function after rhinoplasty executive summary . Otolaryngol Head Neck Surg 2017; 156: pp. 205-219. Supplement: 156(2S):S1-S30, 2017 .
14.Phillips K.A.: Pharmacotherapy and other somatic treatments for body dysmorphic disorder . In Phillips K.A. (eds): Body Dysmorphic Disorder: Advances in Research and Clinical Practice . 2017. Oxford University Press , New York pp. 333-355.
15.Castle D., et al.: Body dysmorphic disorder: a treatment synthesis and consensus on behalf of the International College of Obsessive-Compulsive Spectrum Disorders (ICOCS) and the Obsessive Compulsive and Related Disorders Network (OCRN) of the European College of Neurophsychopharmacology (ECNP) . Int Clin Pharmacol 2021; 36: pp. 61-75.