Body dysmorphic disorder (BDD), formerly referred to as dysmorphophobia, is a severe psychiatric disorder that involves a preoccupation with an imagined defect in one's physical appearance.
The focus may be on any body part, but typically the complaint involves flaws of the face and hair such as a crooked smile, uneven lips or misshapen head, or is expressed as an overall feeling of ugliness.
Individuals with body dysmorphic disorder obsess over this imaginary or barely noticeable body flaw to the point that it has significant negative repercussions on their relationships and quality of life. No amount of reassurance can convince an individual with BDD that the perceived defect is not real.
Body dysmorphic disorder is often overlooked in clinical settings. However, when properly identified, it can be successfully treated with medication and cognitive behavioral therapy (CBT).
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Here are some key points about body dysmorphic disorder. More detail and supporting information is in the main article.
- Body dysmorphic disorder was first described more than 100 years ago and is seen throughout the world
- The onset of BDD is typically during adolescence
- It can take as long as 17 years before BDD is diagnosed, however, because many patients are too ashamed to disclose their symptoms to their health care provider
- Body dysmorphic disorder is believed to have a genetic component
- It is estimated to affect 1-2% of the general US population, and 7-15% of patients undergoing plastic or cosmetic surgery
- More than 90% of people with BDD report symptoms that are unchanged or worse after cosmetic procedures
- Individuals with body dysmorphic disorder often have other illnesses such as depression, social phobia and obsessive-compulsive disorder (OCD)
- Individuals with BDD may have few or no friends; more than 20% are unemployed, and 55% are unmarried
- Untreated body dysmorphic disorder increases the likelihood of suicide.
What is body dysmorphic disorder?
Individuals with BDD obsess that there is something wrong with how they look, even though the perceived flaw in their appearance is minimal or nonexistent. The condition has little to do with real physical appearance but rather an individual's body image, or self-perception.
People with body dysmorphic disorder are preoccupied with a defect in their appearance which can be minor or imaginary.
Body dysmorphic disorder has three criteria for diagnosis:
- There is a preoccupation with a defect in the appearance - the defect is either imagined or, if a minor defect is present, the individual's concern is excessive
- The preoccupation causes significant distress in social, occupational and other important areas of functioning
- The preoccupation is not better accounted for by another mental disorder (such as anorexia nervosa or hypochondriasis).
Individuals also seek continual reassurance and get frustrated when others do not see the defect. Many have delusions of reference, meaning they think that other people stare at their defect, talk about it or mock it.
Individuals may become so distraught over their appearance that they may stop working and socializing, becoming housebound because they believe that they are too hideous to be seen in public.
Causes of body dysmorphic disorder
The exact cause of body dysmorphic disorder is unknown although numerous theories have been suggested. It may be an inherited condition as the prevalence of BDD is four times higher in first-degree relatives of people with body dysmorphic disorder.
Body dysmorphic disorder also appears to be related to OCD; BDD frequently occurs in people with OCD and their relatives, and responds to the same treatment.
Functional abnormalities in the visual processing and limbic systems of the brain have also been identified as a potential cause. Finally, low levels of the neurotransmitter serotonin may be a contributing factor.
Some research suggests that early sexual, emotional or physical abuse could be a potential risk factor in the development of BDD.
Symptoms of body dysmorphic disorder
The core component of body dysmorphic disorder is a preoccupation with an imagined defect in appearance or an excessive reaction to a slight physical flaw. It is a chronic disorder that can grow and reduce in intensity, and may shift from one body part to another.
Common areas of perceived imperfections involve the skin (acne, greasiness, wrinkles), face (excessive facial hair), nose, mouth, teeth, baldness, breasts or genitals.
Typical behaviors associated with body dysmorphic disorder include:
People with body dysmorphic disorder can be fixated with viewing their reflection in mirrors, or may try to avoid them altogether.
- Preoccupation with physical appearance with extreme self-consciousness
- Obsessively touching, picking, measuring or staring at the defect
- Excessively reading or researching the defect
- Neglecting more important aspects of life such as work, family and personal health and well-being
- Fixation on or avoidance of mirrors - compulsive mirror checking, glancing in reflective doors, windows and other reflective surfaces, or removing all mirrors in the home
- Going to great lengths to conceal the defect using items such as wigs, hats and makeup
- Repeated dermatological or cosmetic referrals for corrections of the defect.
Individuals with body dysmorphic disorder report thinking about their perceived appearance flaws for an average of 3-8 hours a day, and have only limited control over these thoughts. Attempts to explain that the physical defect is either nonexistent or minor will be futile; individuals with body dysmorphic disorder will continue to agonize over their perceived flaws.
Tests and diagnosis of body dysmorphic disorder
Medical providers often overlook the diagnosis of BDD due to both a lack of knowledge of the disorder and the individual's reluctance to disclose their concerns due to shame.
Although body dysmorphic disorder is a psychiatric condition, very few individuals ever see a psychiatrist as they regard their problem as physical rather than psychological. Instead, people with BDD often seek treatment from orthodontists, dermatologists, cosmetologists and plastic surgeons.
As body dysmorphic disorder is diagnosed solely through clinical history and interview, it is important that patients undergoing cosmetic procedures are screened using a BDD questionnaire such as The Body Dysmorphic Disorder Questionnaire-Dermatology Version (BDDQ-DV).
Treatment for body dysmorphic disorder
Treatment of body dysmorphic disorder typically includes cognitive behavioral therapy (CBT), medication and behavioral counseling.
Cognitive behavioral therapy (CBT): helps people reduce problematic behaviors by challenging their beliefs and negative thinking. CBT helps individuals gain insight and stop automatic negative thoughts while learning to self-evaluate in a more realistic and positive way. Individuals can also learn healthy ways to handle urges or rituals, such as mirror checking or skin picking.
Medication: SSRI antidepressants such as fluoxetine, fluvoxamine and citalopram have shown success in the treatment of BDD.
Family therapy: a mental health professional can identify maladaptive beliefs and behaviors within the family, and identify more effective approaches to dealing with these behaviors.
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Body dysmorphic disorder is a severe psychiatric disorder that is exhibited as excessive preoccupation with one's appearance and a minor or imagined physical defect. As it is under-recognized in clinical settings, individuals with BDD are often not properly diagnosed and treated, and have a poor quality of life.
Medical providers, family members and teachers of high-risk individuals need to be aware of the condition and refer people for mental health evaluation as necessary. Measures to prevent unnecessary surgical procedures in these individuals are also needed.
As body dysmorphic disorder is a chronic condition, individuals require long-term mental health treatment and follow-up appointments. Over time, individuals with BDD achieve the best results when treated by a consistent medical and mental health team using a combination of medications and behavioral therapy.
