Body dysmorphic disorder
|Body Dysmorphic Disorder|
|Classification and external resources|
Body dysmorphic disorder (BDD, also body dysmorphia ; originally dysmorphophobia) is a type of mental illness, a somatoform disorder, wherein the affected person is concerned with body image, manifested as excessive concern about and preoccupation with a perceived defect of their physical features. The person thinks they have a defect in either one feature or several features of their body, which causes psychological distress that causes clinically significant distress or impairs occupational or social functioning. Often BDD co-occurs with depression and anxiety, social withdrawal or social isolation.
The causes of body dysmorphic disorder are different for each person, usually a combination of biological, psychological, and environmental factors. Certain types of psychological trauma stemming from mental and physical abuse, or emotional neglect, can contribute to a person developing BDD. The onset of the symptoms of a mentally unhealthy preoccupation with body image occurs either in adolescence or in early adulthood, whence begins self-criticism of the personal appearance, from which develop atypical aesthetic-standards derived from the internal perceptual discrepancy between the person's ‘actual self’ and the ‘ideal self’. The symptoms of body dysmorphia include depression, social phobia, and obsessive compulsive disorder. The affected individual may become hostile towards family members for no reason.
BDD is linked to a diminished quality of life, can be co-morbid with major depressive disorder and social phobia (chronic social anxiety); features a suicidal ideation rate of 80 percent, in extreme cases linked with dissociation, and thus can be considered a factor in the person's attempting suicide. BDD can be treated with either psychotherapy or psychiatric medication, or both; moreover, cognitive behavioural therapy (CBT) and selective serotonin reuptake inhibitors (SSRIs) are effective treatments. Although originally a mental-illness diagnosis usually applied to women, body dysmorphic disorder occurs equally among men and women, and occasionally in children and older adults. About 76% of parents think their child is either over conceited or simply lying about their condition. Approximately one to two percent (1–2%) of the world's population meets the diagnostic criteria for body dysmorphic disorder.
The Diagnostic and Statistical Manual of Mental Disorders defines body dysmorphic disorder as a somatoform disorder marked by a preoccupation with an imagined or trivial defect in appearance that causes clinically significant distress or impairment in social, occupational or other important areas of functioning. The individual's symptoms must not be better accounted for by another disorder; for example, weight concern in the case of anorexia nervosa. 
The disorder generally is diagnosed in those who are extremely critical of their mirror image, physique or self-image, even though there may be no noticeable disfigurement or defect. The three most common areas of which those suffering from BDD will feel critical have to do with the face: the hair, the skin, and the nose. Outside opinion will typically disagree and may protest that there even is a defect.
People with BDD say that they wish that they could change or improve some aspect of their physical appearance even though they may generally be of normal or even highly attractive appearance. Body dysmorphic disorder may cause sufferers to 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. This can cause those with this disorder to begin to seclude themselves or have trouble in social situations. More extreme cases may cause a person to develop love-shyness, a chronic avoidance of all intimate relationships. They can become secretive and reluctant to seek help because they fear that seeking help will force them to confront their insecurity. They may feel too embarrassed and unwilling to accept that others will tell the sufferer that they are suffering from a disorder. The sufferer believes that fixing the "deformity" is the only goal, and that if there is a disorder, it was caused by the deformity. In extreme cases, patients report that they would rather suffer from their symptoms than be 'convinced' into believing that they have no deformity. It has been suggested that fewer men seek help for the disorder than women.
BDD is often misunderstood as a vanity-driven obsession, whereas it is quite the opposite; people with BDD do not believe themselves to be better looking than others, but instead feel that their perceived "defect" is irrevocably ugly or not good enough. People with BDD may compulsively look at themselves in the mirror or, conversely, cover up and avoid mirrors. They typically think about their appearance often 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. Chronic low self-esteem is characteristic of those with BDD, because the assessment of self-value is so closely linked with the perception of one's appearance.
Phillips & Menard (2006) found the completed-suicide rate in patients with BDD to be 45 times higher than that of 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. Suicidal ideation is also found in around 80% of people with BDD. There has also been a suggested link between undiagnosed BDD and a higher-than-average suicide rate among people who have undergone cosmetic surgery.
There are many common symptoms and behaviors associated with BDD. Often these symptoms and behaviors 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. Due to this perception dependency many BDD sufferers will only display a few common symptoms and behaviors.
Common symptoms of BDD include:
- Obsessive thoughts about (a) perceived appearance defect(s).
- Obsessive and compulsive behaviors related to (a) perceived appearance defect(s) (see section below).
- Major depressive disorder symptoms.
- Delusional thoughts and beliefs related to (a) perceived appearance defect(s).
- Social and family withdrawal, social phobia, loneliness and self-imposed social isolation.
- Suicidal ideation.
- Anxiety; possible panic attacks.
- Chronic low self-esteem.
- Feeling self-conscious in social environments; thinking that others notice and mock their perceived defect(s).
- Strong feelings of shame.
- Avoidant personality: avoiding leaving the home or only leaving the home at certain times.
- Dependent personality: dependence on others, such as a partner, friend or family.
- Inability to work or an inability to focus at work due to preoccupation with appearance
- Problems initiating and maintaining relationships (both intimate relationships and friendships).
- Alcohol and/or drug abuse (often an attempt to self-medicate).
- Repetitive behavior (such as constantly (and heavily) applying make-up; regularly checking appearance in mirrors; see section below for more associated behavior).
- Seeing slightly varying image of self upon each instance of observing a mirror or reflective surface.
- Perfectionism (undergoing cosmetic surgery and behaviors such as excessive moisturizing and exercising with the aim to achieve an ideal body type and reduce anxiety).
- Note: any kind of body modification may change one's appearance. There are many types of body modification that do not include surgery/cosmetic surgery. Body modification (or related behavior) may seem compulsive, repetitive, or focused on one or more areas or features that the individual perceives to be defective.
Common compulsive behaviors associated with BDD include:
- Compulsive mirror checking, glancing in reflective doors, windows and other reflective surfaces.
- Alternatively, inability to look at one's own reflection or photographs of oneself; also, removal of mirrors from the home.
- Attempting to camouflage the imagined defect: for example, using cosmetic camouflage, wearing baggy clothing, maintaining specific body posture or wearing hats.
- Use of distraction techniques to divert attention away from the person's perceived defect, e.g. wearing extravagant clothing or excessive jewelry.
- Excessive grooming behaviors: skin-picking, combing hair, plucking eyebrows, shaving, etc.
- Compulsive skin-touching, especially to measure or feel the perceived defect.
- Immotivated hostility toward people, especially those of the opposite sex (or same sex if homosexual).
- Seeking reassurance from loved ones.
- Excessive dieting or exercising, working on outside appearance.
- Comparing appearance/body parts with that/those of others, or obsessive viewing of favorite celebrities or models whom the person suffering from BDD wishes to resemble.
- Compulsive information-seeking: reading books, newspaper articles and websites that relate to the person's perceived defect, e.g. losing hair or being overweight.
- Obsession with plastic surgery or dermatological procedures, often with little satisfactory results (in the perception of the patient). In extreme cases, patients have attempted to perform plastic surgery on themselves, including liposuction and various implants, with disastrous results.
- Excessive enema use (if obesity is the concern).
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;
People with BDD often have more than one area of concern.
There is comorbidity with other psychological disorders, which often results in misdiagnoses by medical individuals. New research indicates that around 76% of people with BDD will experience major depressive disorder at some point in their lives, significantly higher than the 10–20% expected in the general population. Nearly 36% of people with BDD will also present with agoraphobia and around 32% are also affected by obsessive–compulsive disorder.
The most common disorders found in individuals with BDD are avoidant personality disorder, social phobia, social anxiety disorder, borderline personality disorder and dependent personality disorder, which conforms to the introverted, shy and neurotic traits usually found in BDD sufferers. Eating disorders are also sometimes found in people with BDD, as are trichotillomania, dermatillomania, and sub-type disorders Olfactory Reference Syndrome and muscle dysmorphia.
BDD usually develops in teenagers, a time when individuals are most concerned about the way they look to others. However, many patients suffer for years before seeking help. There is no single cause of body dysmorphic disorder; research shows that a number of factors may be involved and that they can occur in combination. BDD can be associated with eating disorders, such as compulsive overeating, anorexia nervosa or bulimia, or it can be more of a phobia, associated instead with social phobia or social anxiety disorder.
BDD can often occur with obsessive–compulsive disorder (OCD) and is regarded as an obsessive compulsive spectrum disorder along with OCD, hypochondria, trichotillomania, anorexia nervosa etc. In all these conditions the patient practices unmanageable habitual behaviors that may literally take over their life. A history of, or genetic predisposition to OCD may make people more susceptible to BDD. Other phobias like social anxiety disorder may also be co-occurring.
Skin conditions such as acne vulgaris are among the most common sources of distress of patients with BDD, especially in cases where the condition is severe such as cystic acne on a persons back, chest or face etc. BDD does not necessarily go away even once the acne clears as scarring caused by the acne often becomes the new "defect" in which the person focuses on, as can other skin conditions such as pigmentation or moles. The prevalence of acne in those with BDD has led to a subset of the condition called "Acne Dysmorphia".
Eczema, baldness, dermatosis papulosa nigra, freckles, scarring, skin tone and other physical traits such as body size and weight can also factor into the onset of BDD via low self-esteem and negative thinking.
Parenting style may contribute to BDD onset; for example, parents who either place excessive emphasis on aesthetic appearance, or disregard it altogether, may act as a trigger in the genetically predisposed.
Other life experiences
Many other life experiences may also act as triggers to BDD onset; for example, neglect, physical and/or sexual trauma, insecurity and rejection.
It has been theorized that media pressure may contribute to BDD onset; for example, glamour models and the implied necessity of aesthetic beauty. However, BDD occurs in all parts of the world, including isolated areas where access to media is limited or (practically) non-existent. Media pressure is therefore an unlikely cause of BDD, although it may act as a trigger in those already genetically predisposed or could worsen existing BDD symptoms.
- Sensitivity to rejection or criticism
- Avoidant personality
- Schizoid personality
- Social phobia
- Social anxiety disorder
Since personality traits among people with BDD vary greatly, it is unlikely that these are the direct cause of BDD. However, like the aforementioned psychological and environmental factors, they may act as triggers in individuals.
There is evidence that individuals with BDD have abnormal visual processing when viewing their own face, others' faces, and inanimate objects. However, it is still unclear if these phenomena are the cause or effect of having BDD.
According to the DSM IV to be diagnosed with BDD a person must fulfill the following criteria:
- "Preoccupation with an imagined or slight 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)."
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. This under-diagnosis is due to the disorder only recently being included in DSM IV; therefore, clinician knowledge of the disorder, particularly among general practitioners, is not widespread.
Also, BDD is often associated with shame and secrecy; therefore, patients often fail to reveal their appearance concerns for fear of appearing vain or superficial.
BDD is also often misdiagnosed because its symptoms can mimic that of major depressive disorder or social phobia. and so the cause of the individual's problems remain unresolved.
Many individuals with BDD also do not possess knowledge or insight into the disorder and so regard their problem as one of a physical rather than psychological nature; therefore, individuals suffering from BDD may seek cosmetic treatment rather than mental health treatment.
Studies have found that cognitive behavior therapy (CBT) is effective in the majority of cases. In a study of 54 BDD patients 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.
Since BDD is believed to be linked to low serotonin levels in the brain, SSRIs (selective serotonin reuptake inhibitors) and other antidepressants are commonly prescribed. 74 subjects were enrolled in a placebo-controlled study group to evaluate the efficiency of fluoxetine (Prozac); patients were enrolled in a 12-weeks, double-blind, randomized study. At the end of treatment, 53% of patients responded to fluoxetine (with 18% of patients responding to the placebo).
A combined approach of cognitive behavior therapy (CBT) and antidepressants is more effective than either alone. The dose of a given antidepressant is usually more effective when it exceeds the maximum recommended doses that are given for obsessive compulsive disorder (OCD) or a major depressive episode.
If a person becomes aware that they have BDD then it is also possible to overcome the problem with regular positive self-affirmations and to acknowledge that the "defects" they have convinced themselves of are not an issue. Although this is dependent on the environment in which one lives as bullying, harassment and other negative influences would counteract or hinder progress in developing personal self-confidence.
Many individuals with BDD have repeatedly sought treatment from dermatologists or cosmetic surgeons with little satisfaction before finally accepting psychiatric or psychological help. Plastic surgery on these patients can lead to manifest psychosis, suicidal tendencies or never-ending requests for more surgery. Treatment can improve the outcome of the illness for most people. However, some may function reasonably well for a time and then relapse, while others may remain chronically ill. Outcome without therapy has not been researched but it is thought the symptoms persist unless treated.
Studies show that BDD is common in not only non-clinical settings but clinical settings as well. A study was performed on 200 people with DSM-IV Body Dysmorphic Disorder, being of age 12 or older and being available to be interviewed in person. They were referred by mental health professionals, friends and relatives, non-psychiatric physicians or responded to advertisements. Out of the subjects, 53 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 a Body Dysmorphic Disorder Examination Sheet. Both tests were designed specifically to assess BDD. The results showed that BDD occurs in 0.7–1.1% of community samples and 2–13% of non-clinical samples. 13% of psychiatric inpatients were diagnosed with BDD. Some of the patients initially diagnosed with obsessive-compulsive disorder (OCD) had BDD, as well.
53 patients with OCD and 53 patients with BDD were compared on clinical features, comorbidity, family history, and demographic features. Nine of the 62 subjects (14.5%) of those with OCD also had BDD.
The disorder was first documented in 1886 by the researcher Morselli, who dubbed the condition "dysmorphophobia". BDD was recognized by the American Psychiatric Association in 1987 and was recorded and formally recognized as a disorder in 1987 in the DSM-III-R. It has since been changed from "dysmorphophobia" to "body dysmorphic disorder" because the original implies a phobia of people, not a reluctance to interact socially because of poor body image.
In his practice, Freud 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 such an extent it greatly limited his functioning. It even came to the point where "The Wolf Man" wouldn't go out in public for fear of being scrutinized by others around him.
- Anorexia nervosa
- Anxiety disorders
- Body integrity identity disorder
- Body modification
- Bulimia nervosa
- Clinical depression
- Compulsive overeating
- Eating disorder
- Inferiority complex
- Muscle dysmorphia
- Obsessive–compulsive disorder
- Olfactory Reference Syndrome
- Perfectionism (psychology)
- Social phobia
- Social anxiety disorder
- Somatoform disorders
- Species dysphoria
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