Body Dysmorphic Disorder

What is Body Dysmorphic Disorder?

Body dysmorphic disorder (BDD) is a mental health condition where a person is overly worried about a perceived flaw in their appearance, even if they look normal to others. This condition is often overlooked, but is quite common. People with BDD become excessively concerned about imaginary physical imperfections, which can lead to repetitive and distressing behaviors, including thoughts of suicide. In some cases, people may also seek unnecessary cosmetic surgeries.

The American Psychiatric Association’s ‘Diagnostic and Statistical Manual of Mental Disorders’ has changed how it categorizes BDD over the years. Starting in 1980, it was first classified as an unusual type of somatoform disorder (a condition where a person experiences physical symptoms that cannot be explained by a medical condition), but it is now listed under the spectrum of obsessive-compulsive and related disorders. This means that people with BDD obsess over a flaw they think they have in their appearance, even if others can’t see it or only see it slightly. These worries can severely impact their ability to function socially, academically, or occupationally. To be diagnosed with BDD, a person must show repetitive behaviors, like constantly checking themselves in the mirror, trying to hide the perceived flaw with makeup or clothes, picking at their skin, excessive grooming or weight lifting, or mentally comparing their appearance to others. These behaviors take up a lot of time, are hard to control, and cause distress.

BDD is often missed in diagnosis, and people with this disorder often seek help from dermatologists or plastic surgeons to fix the flaws they perceive. Understanding the characteristics and diagnostic criteria of BDD can raise awareness and recognition of the condition in all areas of healthcare.

The term “body dysmorphic disorder” has roots in the late 19th century. In 1891, Italian psychiatrist Enrico Morselli first used the term ‘dysmorphophobia’, which comes from the Greek word for ugliness, to describe people who perceived themselves as flawed despite no visible physical deformities. French psychologist Pierre Janet also wrote about these cases, and even Sigmund Freud described a man known as ‘Wolf Man’ who was obsessed with his nose to the point of suffering serious social difficulties.

What Causes Body Dysmorphic Disorder?

Body dysmorphic disorder (BDD), a condition where a person obsesses over perceived flaws in their appearance, experts believe stems from a combination of psychological, social, and biological factors. While there is a need for more extensive research on the causes of BDD, some studies have provided insights into this condition.

One such study involved brain screening techniques and looked at whether certain physical changes in the brain might cause or result from BDD. However, it’s important to note that these findings are still in the early stages.

In another small study with 57 participants with BDD and 58 without, researchers found a specific gene-named GABA-A-gamma-2 (5q31.1-q33.2) tied to BDD. This gene appeared more often in people with the disorder than in those without it.

Twin research also indicated that genetics could play a role in BDD, with an estimated 43% of the disorder potentially stemming from genetic factors.

Aside from biological factors, psychological and environmental factors also contribute to BDD. For instance, past traumas like physical or sexual abuse might play a role in the disorder’s development. Similarly, people who felt neglected by their parents during childhood or received less parental care may have a higher risk of developing BDD.

Risk Factors and Frequency for Body Dysmorphic Disorder

Body Dysmorphic Disorder (BDD) is experienced by people around the world, in all age groups, and in both genders. However, it’s slightly more common in females. Studies have found that about 2-3% of adults and higher education students, and 2-5% of adolescents, are affected by BDD.

It is quite common for those with BDD to seek cosmetic surgery. Around 13% of patients at general cosmetic surgery clinics, 20% of those seeking nose-related surgery (rhinoplasty), and 11% of people looking for jaw surgery have BDD. Even 5-10% of patients looking for orthodontic treatment are afflicted with this disorder. Some individuals with BDD even travel abroad to other countries for medical treatments and surgery.

BDD is often found alongside other psychiatric conditions like anxiety, depression, psychotic disorders, or bipolar spectrum disorders. The prevalence of BDD in inpatient psychiatric treatment is about 7%, and outpatient treatment about 6%. But people with obsessive-compulsive disorder (OCD) or eating disorders may have an even higher chance of also having BDD.

Signs and Symptoms of Body Dysmorphic Disorder

People suffering from Body Dysmorphic Disorder (BDD) often obsess over minor or non-existent physical flaws, spending an average of 3 to 8 hours a day consumed by these thoughts. These obsessions can focus on a single body part, or they can spread across multiple areas. On average, people with BDD worry about 5 to 7 different body parts. Any physical feature can become a perceived flaw. The most common areas of concern include skin, hair, nose, stomach, breasts, and eyes. Men with BDD often obsess over genital size and balding, whereas women are more likely to worry about areas where body fat is stored, such as the breasts, legs, hips, buttocks, and waist.

• Obsession over minor or non-existent physical flaws
• Thoughts consume 3 to 8 hours a day
• Can focus on one or multiple body parts
• Common areas of concern include skin, hair, nose, stomach, breasts, and eyes
• Men often worry about genital size and balding
• Women often focus on areas of body fat

People with BDD believe they look ugly or deformed, leading to significant emotional distress. This distress often leads to repetetive behavior, like constantly hiding, camouflaging, mirror checking, excessive grooming, clothes changing, excessive exercise, inspecting the concerning part of body, obtaining reassurance, comparing, counting, and self-assuring. These actions help them cope with the stress related to the obssesive thoughts. Sometimes, these rituals may not be apparent to others if they are only mental, like comparing, counting or self-assuring.

In cases where people have visible wounds from skin-picking or hair-pulling, this condition becomes readily apparent. A doctor might even witness compulsive behavior during an examination, like skin-picking, hair-styling, camouflaging, counting, or self-assuring. In both psychiatric and non-psychiatric settings, medical professionals will differentiate between real and perceived defects during a physical examination, focusing most on areas that the patient is most concerned about.

Testing for Body Dysmorphic Disorder

Body Dysmorphic Disorder (BDD) is a condition that is often not properly identified. Indications of BDD can include depression and anxiety that don’t respond to treatment, a history of cosmetic procedures that didn’t quite fix the issue, previous use of substances to ease emotional distress or to avoid social situations, or the feeling of constantly being ridiculed by others.

If a person is pursuing cosmetic procedures that seem unnecessary, this could suggest they may be dealing with BDD. Carrying out screenings in settings such as mental health clinics, substance abuse centres, or even cosmetic procedure clinics could help us identify people with BDD more effectively. There are self-report questionnaires available, like the Body Image Disturbance or the Body Dysmorphic Disorder Questionnaires, which can also help. It’s crucial to ask patients directly about their symptoms – they often won’t voluntarily share this information otherwise.

If you suspect someone has Body Dysmorphic Disorder, they should be referred for a psychiatric evaluation. The objective of this initial evaluation is to establish trust, collect a thorough history related to the issue, and conduct an assessment of their mental state. It’s important to handle psychiatric interview questions sensitively and without judgement. When dealing with BDD, establishing good rapport with a patient is essential because they may be reluctant to share their experiences or get involved in their own treatment plan. Focused interview questions should address each of the DSM-5-TR diagnostic criteria for BDD – a recognized diagnostic tool for mental health disorders.

Here’s the criteria for Body Dysmorphic Disorder according to DSM-5-TR:

1. The individual is extremely concerned about one or more perceived defects or flaws in their physical appearance that others can’t see or see only a little.
2. They engage in repetitive behaviors.
3. These concerns cause significant distress or impact critical areas of their life functioning.
4. These concerns aren’t better explained by an eating disorder.

If a patient is mainly concerned that their muscles or physique are too small, we specify that and diagnose them with “body dysmorphic disorder with muscle dysmorphia.” If they also experience panic attacks due to BDD, their diagnosis is “body dysmorphic disorder with panic attacks.”

Assessing a patient’s level of insight into their condition can help determine the best course and expectations of treatment. Those with good or fair insight acknowledge that their thoughts about their body aren’t true or are likely not true. Patients with poor insight still believe their thoughts are likely true, while those without insight or with delusional beliefs stick rigidly to their beliefs, regardless of what others say.

Usually, lab tests and imaging aren’t necessary unless the patient has been engaging in extreme behaviors that could harm their physical health.

Treatment Options for Body Dysmorphic Disorder

People often look for surgical solutions to what they perceive as physical imperfections. However, surgery usually doesn’t provide an effective solution. A mix of medications and psychological therapy (cognitive behavioral therapy or CBT) can help. The choice of medication is often based on our understanding of how to treat obsessive-compulsive disorder, a condition somewhat similar to this because it also causes people to fixate on specific thoughts or behaviors.

Developing a strong bond with your healthcare professional is an essential part of dealing with this condition. The professional won’t just listen to your worries but will also guide you on treating your condition, explaining what it is and how it works. Remember, they are not there to discuss your appearance. The goal is to understand how your preoccupation with your appearance is affecting your everyday life. For example, it may be causing emotional distress, suicidal thoughts, avoidance of social situations, problems at work or school, and conflicts with others.

Getting cosmetic procedures isn’t advised because they rarely help with this condition’s symptoms. Instead, they may worsen things by adding financial stress.

CBT is a big part of treating this condition. This therapy type targets the destructive beliefs that are at the core of this condition. It involves learning, relaxation exercises, enhancing coping skills, and managing stress. Even if it’s difficult to access therapy services, studies show that receiving CBT through online platforms can still be effective.

When the condition is severe, a technique known as motivational interviewing can be used to help someone who’s reluctant to start treatment.

Medications are often used as treatment because they’re easier to access than therapy. Selective serotonin reuptake inhibitors (SSRIs), which are typically used to treat depression and anxiety, are often used. Even though they’re not specifically approved by the FDA for treating this body image condition, studies have shown that they can be effective. These medications are generally well-tolerated, but they often need to be given in higher doses than what’s FDA-approved.

If a patient doesn’t respond to SSRIs, another medication called clomipramine can be added. Clomipramine is primarily used to treat obsessive-compulsive disorder, another condition that causes persistent, unwanted thoughts or behaviors. However, it’s usually considered a second-line treatment because it can cause significant side effects compared to SSRIs.

There’s ongoing research on how these medications work and how they might affect serotonin (a chemical in the brain known to impact mood and anxiety) and other brain chemicals in patients with obsessive-compulsive disorder. These medications have been shown to reduce negative thoughts about one’s body and compulsive behaviors. SSRIs and clomipramine are also known to treat depression and anxiety disorders, which are commonly seen in people with this condition.

Other potential medications to add to SSRIs include buspirone, a medication that modulates brain chemicals like serotonin; memantine, which affects another brain chemical (glutamate); a second-generation antipsychotic medication; or venlafaxine, a type of antidepressant. Each of these has shown at least some efficacy in small case studies or anecdotal reports.

Finally, it’s crucial to remember that people with body dysmorphic disorder are at high risk for suicidal thoughts and behaviors. Those who have active suicidal thoughts or have recently made a suicide attempt may require hospitalization for their safety.

What else can Body Dysmorphic Disorder be?

Body Dysmorphic Disorder (BDD) often displays symptoms that overlap with other psychiatric illnesses, which can cause BDD to sometimes be misdiagnosed or simply unrecognized. It can be tricky to determine, but here are some different reasons why one might mistake BDD for a different condition:

• Normal Behavior Appearance Concern: Many people have worries about how they look, which is normal. However, unlike in BDD, these concerns aren’t paired with obsessive thoughts, over-the-top behaviors, and distress that impairs one’s daily life.
• Obvious Bodily Defects: Some people become preoccupied with apparent physical defects. In these cases, if all other symptoms align with BDD, these individuals may be diagnosed with a different disorder that falls under the BDD umbrella. BDD can also include behaviors like skin picking, resulting in visible physical defects that must also be considered and treated.
• Skin Picking (Excoriation) Disorder: This skin-picking behavior disorder is similar to BDD. However, the primary difference is that the motivation for the behavior isn’t to fix a perceived appearance flaw.
• Trichotillomania (Hair-pulling Disorder): This disorder involves the irresistible urge to pull out hair. If the hair-pulling is consistent with efforts to fix a perceived bodily flaw, it might be BDD instead of trichotillomania.
• Isolated Dysmorphic Concern: Sometimes, individuals have concerns about their body that are unfounded and don’t involve any repetitive or compulsive behaviors. These individuals might worry about body odor, for instance. In these cases, BDD likely isn’t the right diagnosis, but it’s also not clear what other diagnosis, if any, fits.
• Obsessive-Compulsive Disorder: It’s essential to distinguish between BDD and Obsessive-Compulsive Disorder (OCD) because they both fall under the same broad category. Both disorders involve repetitive, intrusive thoughts that significantly impact daily life. However, with BDD, these thoughts and behaviors specifically center around perceived flaws in physical appearance.
• Gender Dysphoria: Much like BDD, gender dysphoria involves a desire to change a physical attribute which leads to distress and impacts daily life. The difference lies in what physical characteristic concerns the individual. Those with gender dysphoria are focused on their primary or secondary sex characteristics, instead of perceived flaws in physical appearance.
• Eating Disorders: Individuals with anorexia nervosa, bulimia nervosa, or BDD all suffer from a distorted image of their body. Both conditions can lead to harmful behaviors to alter their appearance. However, disorders would be diagnosed separately if the person meets the diagnostic criteria for both.
• Major Depressive Disorder: Unfortunately, many people with BDD also have major depressive disorder. A diagnosis for both may occur if the individual meets the criteria for each. Yet, some people may only be diagnosed with BDD, even if they exhibit symptoms of depression.
• Social Anxiety Disorder: Those with BDD might begin to avoid social situations due to fears of judgment about their appearance, just as those with Social Anxiety Disorder (SAD) do. The distinction lies in that SAD usually correlates with a fear of being negatively judged for what they say or do, rather than appearance. Furthermore, obsessions or compulsive behaviors often associated with BDD are not present in SAD.
• Delusional Disorder: In severe cases, people with BDD can have delusional beliefs about their appearance. On the other hand, issues with delusion in BDD can range from catered beliefs about a minor defect to full-blown false beliefs about appearance. In contrast, compulsive behaviors aren’t typical for those with delusional disorder.

In summary, while BDD may share symptoms with several psychiatric disorders, it’s crucial to differentiate between them for accurate diagnosis and treatment. Each condition involves unique characteristics that differentiate it from BDD.

What to expect with Body Dysmorphic Disorder

People undergoing treatment for Body Dysmorphic Disorder (BDD), which may include medication, therapy, or a combination of both, are thought to see improvements in their condition between 50% and 80% of the time within a span of 4 to 16 weeks. To prevent the disorder from recurring, ongoing treatment is suggested. However, the exact duration needed for this maintenance treatment is not clearly defined.

Possible Complications When Diagnosed with Body Dysmorphic Disorder

Having Body Dysmorphic Disorder (BDD) can make it challenging to function normally in social relationships, handle emotions efficiently, and perform well at work or school. The disorder can greatly diminish the quality of life for the person suffering. Because BDD leads to serious emotional and psychological challenges, it’s common for people with BDD to develop additional mental health disorders. It’s been found that nearly 75% of people with BDD also suffer from major depressive disorder.

Commonly Associated Disorders:

• Major depressive disorder
• Social anxiety disorder
• Substance use disorders
• Obsessive-compulsive disorder
• Variety of personality disorders
• Eating disorders

Alongside these mental health challenges, BDD can also make a person more susceptible to thoughts about suicide. It is distressing but around 50% of those suffering from BDD experience thoughts of suicide. It has also been estimated that 1 out of 4 patients with BDD tries to commit suicide.

Preventing Body Dysmorphic Disorder

Body Dysmorphic Disorder (BDD) is a condition where people spend a lot of time worrying about what they see as flaws in their physical appearance. Common things that people with BDD obsess over can be their skin, hair, nose, private parts, chest, or overall body shape. These thoughts can be hard to control and often cause a lot of mental stress, taking up several hours of the day.

People with BDD often seek ways to manage their stress. They may repetitively check their looks in the mirror, groom themselves constantly, or seek assurance from others. While these behaviors help temporarily, they can go unnoticed and significantly affect a person’s life.

People often opt for cosmetic surgery, hoping it can fix their perceived flaws. Unfortunately, these surgical solutions aren’t effective. However, with the help of a mental health professional, through cognitive behavioral therapy (a type of therapy that helps people understand and change thought patterns that lead to harmful habits) and possibly medication, many patients with BDD see an improvement in their symptoms.