Part 1

Body dysmorphic disorder (BDD) is a relatively common disorder that consists of a distressing or impairing preoccupation with imagined or slight defects in appearance. BDD is commonly considered to be an obsessivecompulsive spectrum disorder, based on similarities it has with obsessive-compulsive disorder…(1)

“…this disorder is associated with marked impairment in psychosocial functioning, notably poor quality of life, and high suicidality rates. In this review, we provide an overview of research findings on BDD, including its epidemiology, clinical features, course of illness, comorbidity, psychosocial functioning, and suicidality.

Body dysmorphic disorder (BDD) is a DSM-IV disorder that is characterized by a distressing or impairing preoccupation with slight or imagined defect(s) in one’s physical appearance. BDD has been consistently described around the world for more than a century^1,2 Enrico Morselli, an Italian physician who called this disorder “dysmorphophobia,” offered this poignant description in 1891: “The dysmorphophobic patient is really miserable; in the middle of his daily routines, conversations, while reading, during meals, in fact everywhere and at any time, is overcome by the fear of deformity… which may reach a very ;painful intensity, even to the point of weeping and desperation”.³BDD was later described by distinguished psychiatrists such as Emil Kraepelin and Pierre Janet^4,5 and, over the years, numerous case studies have been reported from around the world.⁶

Despite its long history, BDD has been researched in a sustained and systematic way for less than two decades. During this time, much has been learned about the disorder, including its clinical features, epidemiology, and treatment.

Because BDD causes substantial suffering and impairment in functioning, there is a need for increased recognition of this often-debilitating condition across all specialties.¹²

Definition and classification of BDD

Here we provide DSM-IV’s definition of BDD and briefly comment on each diagnostic criterion.

A) “Preoccupation with an imagined defect in appearance. If a slight physical anomaly is present, the person’s concern is markedly excessive.” The most common preoccupations focus on the skin (eg, scarring, acne, color), hair (eg, going bald, excessive facial or body hair), or nose (eg, size or shape), although any body part can be the focus of concern.¹³

B) “The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.” As in other disorders, distress and impairment in functioning vary in terms of severity. But typically, patients experience substantial impairment in social, occupational, and academic functioning, as will be discussed later in this review.

C) “The preoccupation is not better accounted for by another mental disorder (eg, dissatisfaction with body shape and size in anorexia nervosa).” This criterion indicates that if a person’s only appearance concern is that he/she weighs too much or is too fat, and the person meets diagnostic criteria for anorexia nervosa or bulimia nervosa, then the eating disorder, rather than BDD, is diagnosed. However, BDD and eating disorders are frequently comorbid, in which case both disorders should be diagnosed.^16,17

Epidemiology

BDD appears to be relatively common. Epidemiologic studies have reported a point prevalence of 0.7% to 2.4% in the general population.^27–30 These studies suggest that BDD is more common than disorders such as schizophrenia or anorexia nervosa.¹⁵Investigations in nonclinical adult student samples have yielded higher prevalence rates of 2% to 13 %.^31–35

BDD is commonly found in clinical settings, with studies reporting a prevalence of 9% to 12% in dermatology settings, 3% to 53% in cosmetic surgery settings, 8% to 37% in individuals with OCD, 11% to 13% in social phobia, 26% in trichotillomania, and 14% to 42% in atypical major depressive disorder (MDD).^8,36–49 Studies of psychiatric inpatients have found that 13% to 16% of patients have DSM-TV BDD.^9,50 A study of adolescent inpatients found that 4.8% of patients had BDD.¹⁰

These studies indicate that BDD is relatively common. However, these estimates may underreport its prevalence. Many individuals with BDD feel ashamed of their appearance and the fact that they are so focused on it. As a consequence, they may not report their BDD symptoms to clinicians. In one study of psychiatric inpatients, only 15.1% had revealed their body image concerns to their mental health clinicians, and the most common reason for not disclosing their concerns was embarrassment (in 31. 3 %).⁵⁰ Furthermore, in five studies in which adults were systematically screened for BDD, no patient who was found by the researchers to have BDD had the diagnosis of BDD in their medical record.^7–11 The number of patients found to have BDD were as follows: 30 of 30, 11 of 80, 16 of 122, 10 of 208, and 16 of 122.

Appearance preoccupations

The most frequent body areas of concern are the skin (73%), hair (56%), and nose (37%).^52,55 However, any body area can be the focus of preoccupation. On average, over their lifetime, persons with BDD are preoccupied with 5 to 7 different body parts.^52,55Some individuals are preoccupied with their overall appearance; this includes the muscle dysmorphia form of BDD which consists of the belief that one’s body is too small and inadequately muscular.^56–58

Approximately 40% of individuals with BDD actively think about the disliked body parts for 3 to 8 hours per day, and 25% report thinking about them for more than 8 hours per day⁶ These preoccupations are almost always difficult to resist or control, and they are intrusive and associated with significant anxiety and distress.¹

Insight regarding perceived appearance defects

Insight regarding the perceived appearance defects varies. In one sample, 35.6% of participants were classified on the reliable and valid Brown Assessment of Beliefs Scale (BABS59) as delusional – that is, completely certain that their beliefs about how they look were accurate.⁶⁰ Prior to effective treatment, few patients have good insight. Studies have consistently found that insight is poorer in BDD than in OCD, with 27% to 60% of BDD patients having delusional beliefs versus only 2% of OCD patients.^13,61

About two thirds of BDD patients have past or current ideas or delusions of reference, believing that other people take special notice of them in a negative way or mock or ridicule them because of how they look.²³ Clinical impressions indicate that such referential thinking may lead to feelings of rejection and to anger (even violence, such as attacking someone they believe is mocking them).¹

Furthermore, some individuals with BDD describe fluctuations in insight, such that they are completely convinced that they are ugly at some times but not convinced at others.⁶As one patient remarked: “Some days I think my skin’s not so bad, but other days I’m convinced.”¹ Observations such as these offer further support for the view that delusional BDD and nondelusional BDD constitute the same disorder, characterized by a range of insight, rather than being different disorders.

…nearly everyone with BDD performs specific behaviors – such as mirror checking and skin picking, as illustrated in the above case – that are linked to their appearance preoccupations.^52,52 The relationship between thoughts and behaviors in BDD appears similar to the relationship between obsessions and compulsions in OCD. That is, the compulsive behaviors arise in response to the obsessive thoughts about appearance, and are meant to reduce anxiety and other painful emotions.¹³

As in OCD, the behaviors are not pleasurable.¹³

These compulsive behaviors are repetitive, time-consuming (about half of BDD patients spend 3 or more hours per day engaged in them), and hard to control and resist.⁶³ Some behaviors, such as camouflaging disliked body parts (eg, with a hat, makeup, sunglasses), are called safety behaviors, because their function is to reduce or avoid painful emotions or prevent something bad from happening, such as being humiliated or embarrassed.¹Most BDD patients perform multiple compulsive behaviors.^52,55 One common behavior is comparing themselves with other people. Clinical impressions suggest that this usually happens quite automatically, and can cause anxiety and inability to concentrate. About 90% of BDD patients check themselves repeatedly and excessively in mirrors or other reflective surfaces.¹ Typically, they do this in the hope that they look acceptable, but often, after seeing their reflection, they feel worse.⁶⁴ Other common repetitive behaviors are excessive grooming (eg, combing their hair or washing their skin repeatedly), tanning (to improve their skin color or skin imperfections), reassurance seeking (asking whether one’s appearance is acceptable), excessive shopping for beauty products, changing their clothes repeatedly to find a more flattering outfit, and excessive exercise (eg, weightlifting in the case of muscle dysmorphia).^{1,52,55,64–66} Many BDD patients (27% to 45%) pick at their skin in an attempt to improve perceived blemishes or imperfections; however, this behavior sometimes causes observable appearance defects and can even cause severe damage such as skin infections and rupture of blood vessels.^67–69 Many other examples of compulsive behaviors exist, which are often idiosyncratic, such as drinking more than 3 gallons of water a day to make one’s face look fuller.¹

Avoidance is a common behavior in BDD.^70,71 Patients often avoid social situations since they fear being negatively judged by other people because they look “ugly.” They may not take a job where they think they will be scrutinized by others. Avoidance may serve a similar purpose as the compulsive behaviors in the short term – that is, to temporarily relieve BDD-related anxiety and distress. However, clinical experience indicates that compulsions and avoidance seldom improve anxiety or reduce the intensity of BDD-related thoughts; rather these behaviors may contribute to the chronicity and severity of BDD.^1,72

TBC

References

1. Bjornsson, A. S., Didie, E. R., & Phillips, K. A. (2010). Body dysmorphic disorder. Dialogues in clinical neuroscience, 12(2), 221.