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Manual of Articles Sections 15 - 28
BPD is often underdiagnosed and misdiagnosed
BDD appears to be fairly common (Perugi et al., 1998; Phillips, Nierenberg, Brendel, & Fava, 1996; Simeon, Hollander, Stein, Cohen, & Arnowitz, 1995) but is usually missed by clinicians. Several studies that investigated BDD's prevalence in clinical populations found that the patient's clinician missed the diagnosis of BDD in all cases in which it was present (Phillips et al., 1996; Zimmerman & Mattia, 1998). Not diagnosing BDD is problematic because the patient may not feel understood, the patient is not adequately informed about his or her diagnosis and treatment options, and treatment may be unsuccessful. In addition, BDD does not necessarily improve when comorbid disorders improve unless it is a focus of treatment.
BDD can be diagnosed with the following questions:
BDD can be diagnosed if the person reports being preoccupied with some aspect of his or her appearance, or his or her entire appearance. A useful guideline is whether the person thinks about the appearance "flaw" for at least an hour a day, although this cutpoint is not part of BDD's definition. Clinically significant distress or impairment in functioning must also be present.
Clues to the diagnosis include mirror checking or avoidance, comparing with others, seeking reassurance about the perceived flaw, excessive grooming (e.g., hair combing or shaving), skin picking, and camouflaging. Other clues include frequent clothes changing, body measuring, excessive exercising or weight lifting, seeking unnecessary dermatological treatment or surgery, and anabolic steroid use. Most patients have ideas or delusions of reference, social anxiety, and self-consciousness, and some are housebound (Phillips et al., 1994).
In addition to being underdiagnosed, BDD is often misdiagnosed as the following disorders:
The best approach to diagnosing BDD is specifically to ask every patient the questions listed earlier, and to be alert to the clues to BDD. Unless BDD is specifically asked about, the diagnosis is likely to be missed.
However, BDD and OCD also appear to have some notable differences. In the BDD-OCD comparison study (Phillips, Gunderson, et al., 1998), patients with BDD were significantly less likely to be married (13% vs. 39%) and significantly more likely to have had suicidal ideation (70% vs. 47%) or to have made a suicide attempt (22% vs. 8%) due to their disorder. They also had earlier onset of major depression (18.8 +/- 6.5 vs. 25.3 +/- 10.$ years) and higher lifetime rates of major depression (85% vs. 55%), social phobia (49% vs. 19%), and psychotic disorder diagnoses (30% vs. 8%). Their first-degree relatives had a higher rate of substance use disorders. In a study that used the Brown Assessment of Beliefs Scale (Eisen et al., 1998), 20 BDD subjects had significantly poorer insight and a higher rate of ideas/delusions of reference than 20 OCD subjects (Eisen, Phillips, Rasmussen, & Luce, 1997). One way to conceptualize these findings is that BDD is a more depressed, socially phobic, and psychotic "relative" of OCD. BDD and OCD may also have some treatment differences, as described later.
Clinical observations suggest that there are additional differences between BDD and OCD, although these characteristics have not been directly compared in these disorders. Patients with BDD often have profound feelings of shame, embarrassment, and humiliation. Low self-esteem (Rosen & Ramirez, 1998), rejection sensitivity (Phillips et al., 1996), and feeling unlovable also appear more characteristic of persons with BDD than OCD. Another possible difference is less anxiety relief with rituals in BDD; in fact, BDD behaviors (such as mirror checking) often increase rather than decrease anxiety (Phillips, 1996a). In addition, available data suggest that mental health-related quality of life may be poorer in persons with BDD (Phillips, in press) than OCD (Koran, Thienemann, & Davenport, 1996), although comparison studies have not been done.
Until the etiology and pathophysiology of BDD and OCD are elucidated, the exact nature of their relationship will remain unknown. These disorders' etiology and pathophysiology are likely to be multifactorial and complex, involving both genetic (most likely, multiple genes of small effects) and environmental factors. It is likely that some of these disorders' etiological and pathophysiological factors will be shown to overlap and others will be shown to be distinct. More research is clearly needed. In the meantime, the apparent differences between BDD and OCD have some clinical implications: Patients with BDD need to be thoroughly assessed for depressive symptoms, which are common in this disorder and more common than in OCD. Patients with BDD should be carefully assessed and monitored for suicidal ideation and suicidal behavior, which are also common in this disorder. The poorer insight of patients with BDD may have implications for treatment compliance and response (which is discussed further later in this article). Cognitive-behavioral therapy may be less effective for delusional BDD than for OCD (discussed later), although this issue, too, needs to be studied. It is also possible that BDD is less responsive than OCD to exposure and response prevention alone (i.e., without a cognitive component; discussed later), although this question has received little investigation.
The relationship between BDD and depression: BDD has also been postulated to be a symptom of (Carroll, 1994), or related to (Phillips et al., 1994), depression. During the past century, many case descriptions have noted depressive symptoms, suicidal ideation, and suicide attempts in patients with BDD. Hay (1970), for example, in his classic article quotes a 20-year-old women who was obsessed with lines under her eyes and thoughts of suicide: "I am constantly thinking about them, about my face and how I have changed. Make-up is just a waste of time. Life is not worth living" (p. 402).
Also supporting a connection between BDD and depression is the high comorbidity between them. Studies that used structured assessment instruments have found that major depression is the most common comorbid disorder in patients with BDD. In clinical settings, current major depression has been reported in approximately 60% of patients with BDD, and lifetime major depression in approximately 80% (Phillips et al., 1994). Conversely, BDD appears relatively common in patients with major depression. Although one study found that none of 42 patients diagnosed with major depression had BDD (Brawman-Mintzer et al., 1995), larger studies have reported rates of BDD in depressed patients of 8% (of 334 patients; Nierenberg et al., 1995), 14% (of 80 patients; Phillips et al., 1996), and 42% (of 86 patients; Perugi et al., 1998). In one of the studies, BDD was more than twice as common as OCD (Phillips et al., 1996), and in another study (Perugi et al., 1998), it was more common than many other disorders, including OCD, social phobia, simple phobia, generalized anxiety disorder, bulimia nervosa, and substance abuse or dependence.
A number of similarities between BDD and depression also support the theory that they may be related disorders. For example, patients with BDD often report feelings of low self-esteem (Rosen & Ramirez, 1998), shame, rejection sensitivity (Phillips et al., 1996), unworthiness, and defectiveness--feelings often experienced by depressed patients. Such feelings are consistent with the core ideational content of BDD, which involves the belief that one is unattractive, defective, and unappealing. Furthermore, some patients with BDD have prominent feelings of guilt based on the belief that they are responsible for ruining their appearance (for example, due to sun exposure or cosmetic surgery) (Phillips, 1996a). However, such feelings (e.g., guilt, rejection sensitivity) are not specific to depression. In addition, BDD and depression have some notable differences, such as the presence of prominent obsessional preoccupations and repetitive compulsive behaviors. Depressed patients often focus less on their appearance, even neglecting how they look, rather than becoming overfocused on it. And those depressed patients who dislike their appearance are unlikely to selectively and obsessionally focus on this aspect of themselves or to spend hours a day performing compulsive appearance-related behaviors, such as mirror checking and reassurance seeking. Other apparent differences between BDD and depression include a 1:1 gender ratio (Phillips Sc Diaz, 1997), earlier age of onset (Phillips et al., 1993), and often-chronic course (Phillips et al., 1993) for BDD. In addition, in the author's series of 260 BDD patients, onset of BDD usually preceded onset of major depression, suggesting that BDD is not simply a symptom of depression.
BDD and depression do not always respond to treatment concurrently (Phillips, Dwight, Sc McElroy, 1998). Unlike depression, BDD appears to respond to cognitive-behavioral therapy (CBT) but not to other types of psychotherapy alone (Phillips et al., 1993).
Studies of BDD's etiology and pathophysiology are needed to clarify the nature of its relationship to depression. The differences noted suggest that BDD is not simply a symptom of depression, although BDD and depression may be related disorders (Phillips, McElroy, et al., 1995). In some, if not many, patients with BDD, depression appears "secondary" to (i.e., due to) BDD. These conclusions have the following treatment implications: Simply treating depression will often not effectively treat BDD; both BDD and depressive symptoms need to be targeted for treatment. Longer treatment trials (up to 12 or 16 weeks) are often needed to successfully treat BDD and comorbid depressive symptoms (Phillips, Dwight, & McElroy, 1998).
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