Body Dysmorphic Disorder – Causes, Symptoms, Diagnosis, Treatment and Ongoing care

Basics

Description

Body dysmorphic disorder (BDD) is a dysmorphic disorder in which patients have a pervasive subjective feeling of ugliness of some aspect of their appearance despite a normal or near-normal appearance:

  • Diagnostic criteria according to the DSM-IV:
    • Preoccupation with an imagined defect in appearance. If there is a minor physical anomaly, the concern is excessive.
    • The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of function.
    • The preoccupation is not accounted for by another mental disorder.

Epidemiology

  • High comorbidity with depressive disorders
  • Usually begins during adolescence, with a common average age of onset between 15 and 30 years
  • Women are affected somewhat more often than men.
  • Affected patients are likely to be unmarried.
  • Different cultural beliefs may influence or amplify preoccupations:
    • Adolescents usually present similar to adults.
    • Can present in childhood, often with refusing to attend school or planning suicide
  • Onset can be gradual or abrupt.
  • Often a delay in diagnosis until 10–15 years after the onset

Prevalence

  • <1% in general population
  • More common in women than men
  • 5–40% in individuals with anxiety or depressive disorders
  • 6–15% in cosmetic surgery patients and in dermatologic clinics

Risk Factors

  • Genetic predisposition
  • Shyness, perfectionism, or anxious temperament
  • Childhood adversity:
    • Teasing or bullying
    • Poor peer relationships
    • Social isolation
    • Lack of support of family
    • Sexual abuse
  • History of dermatologic or other physical stigmata
  • Being more aesthetically sensitive than average
  • Low self-esteem

Pathophysiology

  • Not well understood
  • A cognitive behavioral model has been described in which an external representation of the person’s appearance (i.e., a photograph or mirror reflection) creates a distorted mental image. Through selective attention, awareness of the image and its specific features is increased. The affected individual becomes preoccupied by the distorted image; this is maintained by various safety and submissive behaviors meant to decrease scrutiny by others, but which may increase the individual’s abnormal self-image and thus reinforces the behavior.
  • Magnetic resonance imaging studies note left cerebral hemisphere hyperactivity, which may imply abnormal visual information processing, leading to selective recall of details and perception of distortions that do not exist (1).

Etiology

Not known, but likely multifactorial involving genetic, biological, and environmental factors

Commonly Associated Conditions

  • Depression
  • Social phobia
  • Bipolar disorder
  • Eating disorders
  • Obsessive-compulsive disorder
  • Suicide (up to 25%)
  • Delusional disorder (27–39%)

Obsessive–compulsive disorder, Body dysmorphic disorder, Eating disorder, Anxiety disorder, Mental health, Major depressive disorder, BDD, sexual abuse history, poor peer relationships, cognitive behavioral model,

Diagnosis

History

  • Determine and validate the patient’s concern.
  • Determine the severity of the disorder.
  • Quantify the amount of time spent worrying about the “distorted” appearance.
  • Determine what is done to hide or eliminate the problem.
  • Determine the degree to which the defect affects school, job, or social life.
  • Rule out other psychiatric disorders.
  • Signs and symptoms may include:
    • Preoccupation that ≥1 features are unattractive, ugly, or deformed
    • Can involve any part of the body, but usually involves the skin, hair, or facial features:
      • Women are more likely to be preoccupied with their weight, hips, legs, and breasts.
      • Men are more likely to be preoccupied with their height, body hair, body build, and genitals.
  • Nature of the preoccupation can change with time
  • Have little insight
  • Tend to display delusions of reference
  • Large amounts of time are consumed by behaviors to examine the perceived defect repeatedly, disguise it, or improve it:
    • Mirror gazing
    • Excessive grooming
    • Camouflaging the “defect”
    • Skin picking
    • Reassurance seeking
    • Dieting
    • Pursuing dermatologic treatment or cosmetic surgery
  • Tend to avoid social interactions
  • Trouble staying in school, maintaining a job, or maintaining significant relationships:
    • Tend to be unhappy with results of dermatologic and cosmetic procedures

Physical Exam

  • Important to do a mental status examination:
    • Look for:
      • Depression
      • Suicidal ideation
      • Anxiety
    • Rule out organic factors by reviewing:
      • Orientation
      • Memory
      • Ability to concentrate
  • Rule out actual physical pathology.

Diagnostic Tests & Interpretation

  • Several modules have been developed to assist with the diagnosis and severity rating of BDD (1).
  • Administered by a trained clinician, these include:
    • The BDD Examination
    • Yale Brown Obsessive–Compulsive Scale modified for BDD

Differential Diagnosis

  • Normal concerns about appearance
  • Eating disorders: BDD differs from an eating disorder in that an eating disorder involves a preoccupation with overall body shape and weight, and with BDD, the preoccupation is with only a specific body part.
  • Obsessive–compulsive disorder (OCD): While BDD may be a version of OCD, the diagnosis differs in that in OCD, the obsessions and compulsions are not just restricted to appearance, as they are in BDD.
  • Gender identity disorder
  • Major depressive episode
  • Narcissistic personality disorder
  • Avoidant personality disorder
  • Social phobia
  • Schizophrenia
  • Trichotillomania
  • Hypochondriasis
  • Delusional disorder, somatic type
  • Koro: A culture-related syndrome seen in Southeast Asia that involves a preoccupation that the genitals (penis, labia, nipples, or breast) are shrinking and disappearing into the abdomen

Treatment

  • In any patient with a coexisting mental disorder, such as a depressive or anxiety disorder, the coexisting disorder should be treated with the appropriate psychotherapy or pharmacotherapy.
  • Cognitive behavior therapy has been shown to be very effective (2,3)[A]:
    • Behavioral experiments
    • Graded exposure tasks
    • Imagery rescripting
    • Cognitive restructuring
    • Reverse role-playing
    • Relaxation
  • Support groups
  • Psychotherapy may be effective.
  • Therapy with and for family members, spouses, or significant others

Medication

  • Results from the small number of available randomized controlled trials suggest that selective serotonin reuptake inhibitors (SSRIs) may be useful in treating patients with BDD (2)[A].
  • SSRIs are currently considered the medication of choice for BDD (4).

First Line

SSRI:

  • Not an approved use by the FDA
  • Patients with and without a delusional disorder did equally well with an SSRI.
  • Maximum tolerated dose should be taken for at least 12–16 weeks
  • Dosages may need to be higher than typically recommended for an eating disorder.

Second Line

Add a low-dose antipsychotic drug to an SSRI if there is failure to respond to ≥2 SSRIs.

Additional Treatment

Issues for Referral

  • Referral to a psychiatrist for diagnosis and therapy can be helpful and necessary for difficult cases.
  • Regular counseling

Surgery/Other Procedures

  • Studies investigating the rate of BDD among persons who seek appearance-enhancing treatments suggest that approximately 5–15% of individuals who seek these treatments suffer from BDD (5).
  • Retrospective reports suggest that persons with BDD rarely experience improvement in their symptoms following these treatments, leading some to suggest that BDD is a contraindication to cosmetic surgery and other treatments.

Ongoing Care

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Follow-Up Recommendations

Patient Monitoring

Many patients have substantial improvement in core BDD symptoms, psychosocial functioning, quality of life, suicidality, and other aspects of BDD when treated with appropriate pharmacotherapy that targets BDD symptoms (4).

Patient Education

  • Phillips KA. The Broken Mirror: Understanding and Treating Body Dysmorphic Disorder. Revised and expanded. New York: Oxford University Press, 2005.
  • Butler Hospital’s Body Dysmorphic Disorder and Body Image Program at http://www.butler.org/body.cfm?id = 123

Prognosis

  • Continuous course with periods of waxing and waning in the intensity of symptoms
  • The longer the duration and the more severe the symptoms, the less the chance of partial or full remission.

Complications

  • Repeated surgical or dermatologic procedures
  • Inability or limited ability to function in society
  • Comorbid conditions
  • Poor social relations
  • Poor self-esteem
  • Suicide

References

1. Feusner et al. Abnormalities of visual processing and frontostriatal systems in body dysmorphic disorder. Arch Gen Psychiatry. 2010;67(2):197–205.

2. Ipser JC, Sander C, Stein DJ. Pharmacotherapy and psychotherapy for body dysmorphic disorder. Cochrane Database Syst Rev. 2009;CD005332.

3. Buhlmann U, Reese HE, Renaud S, et al. Clinical considerations for the treatment of body dysmorphic disorder with cognitive-behavioral therapy. Body Image. 2008.

4. Phillips KA, Hollander E. Treating body dysmorphic disorder with medication: evidence, misconceptions, and a suggested approach. Body Image. 2008.

5. Sarwer DB, Crerand CE. Body dysmorphic disorder and appearance enhancing medical treatments. Body Image. 2008.

6. Albertini RS, Philips KA. Thirty-three cases of body dysmorphic disorder in children and adolescents. J Am Acad Child Psy. 1999;38:453–9.

Additional Reading

American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC: American Psychiatric Association. 2000:507–10.

Philips KA, et al. Predictors of remission from body dysmorphic disorder: a prospective study. J Ner Ment Dis. 2005;193:564–7.

Phillips KA. The Broken Mirror: Understanding and Treating Body Dysmorphic Disorder. Revised and expanded. New York: Oxford University Press, 2005.

Phillips KA. The presentation of body dysmorphic disorder in medical settings. Prim Psychiatry. 2006;13:51–9.

Rief W, Buhlmann U, Wilhelm S, et al. The pre-valence of body dysmorphic disorder: a populationbased survey. Psychol Med. 2006;36:877–85.

Sadock BJ, Sadock VA. Kaplan & Sadock’s Synopsis of Psychiatry, 9th ed. Philadelphia: Lippincott Williams & Wilkins. 2003:653–5.

Slaughter JR, Sun AM. In pursuit of perfection: a primary care physician’s guide to body dysmorphic disorder. Am Fam Physician. 1999;60:1738–42.

Codes

ICD9

300.7 Hypochondriasis

Snomed

83482000 Body dysmorphic disorder (disorder)

Clinical Pearls

  • An eating disorder involves a preoccupation with overall body shape and weight, while in body dysmorphic disorder, the preoccupation is with only a specific body part (6).
  • In obsessive-compulsive disorder, the obsessions and compulsions are not just restricted to appearance, as in body dysmorphic disorder.
  • If the patient insists she has a physical defect and wants it surgically corrected but you don’t appreciate a physical defect, after validating the patient’s concerns, refer to a psychiatrist for further evaluation before performing the procedure. Most patients with body dysmorphic disorder are not content after the procedure, and their concerns persist.

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