Paul, age 30 (not his real name), is preoccupied with pimples on his neck. Yet the only lesions ever visible are ulcers caused by him picking and squeezing his skin. He avoids mirrors because he feels compelled to stare at his neck for long periods of time. He works at night, cleaning a business after everyone has left. He avoids social situations, believing others stare at his neck. Paul always wears a hat and a shirt with a high collar, regardless of the weather. Paul also believes he is overweight, restricts his caloric intake, and induces vomiting at least once a day. He receives disability payments for his diagnoses of body dysmorphic disorder (BDD), anorexia nervosa, and obsessive-compulsive disorder (OCD).
For more than 100 years, practitioners have consistently described the symptoms of BDD. It was first described by Morelli in 1891, who labeled it "dysmorfophobia."³ Phillips called it the "distress of imagined ugliness."² BDD first appeared in the Diagnostic and Statistical Manual(DSM) of the American Psychiatric Association in the revised third edition (DSM-IIIR), where it was classified as a somatoform disorder. BDD is also known as "dermatologic hypochondriasis," "hypochondriacal preoccupation with trivial lesions," and "dermatological nondisease" in the dermatology literature. Body dysmorphic disorder by proxy (obsession with supposed flaws in another person's appearance) has also been described. Thersites complex describes a possible subgroup of patients with BDD who have a minimal physical deformity that causes excessive psychologic distress but may be amenable to surgical correction.
BDD affects up to 2% of the US population, men and women equally. It is grossly underdiagnosed in dermatology and cosmetic surgery settings, where it affects 6% to 15% of patients.
Neuropsychologic testing suggests that patients with BDD have pathology of the frontal systems similar to that seen in OCD. BDD also appears associated with serotonergic dysfunction and impaired executive function.
The essential diagnostic feature of BDD is preoccupation with a specific, imagined defect in appearance. Patients are significantly distressed over the supposed deformity, such that their level of function may be severely affected. This preoccupation is difficult to control, and the patient makes little or no attempt to resist attending to the defect. Although 62% of patients with BDD discussed their symptoms with their primary care physician, BDD can be very difficult to diagnose without a high degree of suspicion and a structured interview. The best indicator that BDD may be present is the degree of preoccupation with appearance and resultant avoidance of occupational and social activity.
Patients with BDD rarely present to a mental health setting, usually seeking treatment from dermatologic or cosmetic surgeons. At diagnosis, half of patients with BDD have consulted a dermatologist or cosmetic surgeon, and many have undergone at least 1 corrective surgical procedure. Unfortunately, patients with BDD respond poorly to attempts to remedy the identified defect. They may demand extensive workups and consultations and often pressure practitioners to prescribe or perform treatments that ultimately prove ineffective in alleviating distress. Patients are usually not satisfied with surgical procedures because of unrealistic and, at times, magical expectations; in fact, symptoms often escalate with such procedures. Typically, patients will have psychiatric symptoms such as depression, anxiety, obsessions and compulsions, or discomfort in social situations. Though any part of the body can be the focus of attention, the face and head are most common. Many patients have several concomitant foci or develop new foci during their illness. Examples of concerns include thinning hair , acne, wrinkles, scars, vascular markings, redness, swelling, and asymmetry. Patients with BDD believe that overall they look fine, and they would have no distress if the particular focus of attention were "normal."
Phillips describes patients with BDD as having a "special and tortuous relationship with mirrors" because frequent mirror gazing is so common. More than 90% of patients with BDD perform repetitive, time-consuming behaviors regarding the imagined defect and may be preoccupied with the defect for many hours per day. They frequently check their imagined defect, excessively groom themselves, compare their area of concern to others', seek reassurance from others, and pick at skin "flaws." The majority of patients attempt to camouflage the area with clothing, makeup, or altered posture. Patients with OCD relieve their anxiety by carrying out compulsive behaviors in response to their obsessive thoughts. In contrast, patients with BDD experience increased anxiety following the behaviors in response to distressing thoughts about the supposed defect.¹ At least half of patients with BDD have poor insight into their disorder and also meet DSM-IV-TR criteria for delusional disorder, somatic type. Most patients have ideas of reference resembling those observed in psychotic patients. The resulting social avoidance and peculiar behaviors may add to a psychotic appearance.
When Does A Cosmetic Concern Become Body Dysmorphic Disorder?
BDD represents the extreme on a continuum of dissatisfaction with physical appearance. A patient's concern with a specific physical feature crosses the line to the psychiatric disorder BDD when the patient's "preoccupation causes significant distress or impairment in social, occupational, or other important areas of functioning." The defect of BDD is not apparent to the examiner (or greatly exaggerated by the patient). By definition, the patient's concern must cause significant impairment of function. Most patients who present to a plastic surgeon for breast augmentation, a urologist for penile-enlargement surgery, an otolaryngologist for rhinoplasty, and so forth, do so simply to change or enhance their appearance in a manner consistent with current cultural standards of beauty. These patients may not be satisfied with their current appearance but do not label the physical feature as defective or abnormal. Their concern is a desire to appear differently and does not impair their level of function in any significant way. In contrast, Paul removed most of the mirrors in his home because of his compulsion to stare at his neck. He avoided social situations during the day and other times when others might see his neck. He wore high-collared shirts and a hat, pulled down to cover much of his face. He also camouflaged his neck by sitting with a shoulder elevated toward the person he was addressing and bent his head slightly down, making it difficult to see his neck.
Men with BDD tend to be preoccupied with loss of scalp hair, body build and height, and appearance of genitals. Women tend to focus on their breasts, hips, and legs, and are more likely to pick their skin. Men and women are equally likely to seek and receive cosmetic surgery. More men are likely to develop muscle dysmorphia (also calledbigorexia orreverse anorexia), defined as a constant preoccupation with perceived inadequate body size and muscle development. Many consider big-orexia to be a form of BDD. Patients with muscle dysmorphia tend to be significantly more muscular than weightlifters without BDD. They may spend more than 3 hours a day thinking about their muscularity, avoid social activities, and they demonstrate little or no control over their compulsive weightlifting and dietary regimen. Men with muscle dysmorphia are much more likely to abuse steroids.
Course Of The Disorder
Onset of BDD symptoms may be abrupt or gradual, usually starting in adolescence. They follow a fairly continuous, chronic course. The majority of patients have few symptom-free intervals; relapse is common with treatment discontinuation. Because of poor insight and the secrecy associated with the behaviors, BDD diagnosis is often delayed for years. One possible risk factor for developing BDD is early traumatic incidents, such as being teased or humiliated over one's physical appearance or being a victim of physical or sexual assault. Dissatisfaction with body image is more likely to be associated with BDD than actual unattractiveness. Half of patients with BDD will be hospitalized at some point for psychiatric symptoms. Self-report scores of mental health-related quality of life of patients with BDD tend to be lower than in patients with affective disorders, OCD, schizophrenia, diabetes mellitus, and recent myocardial infarction. Symptoms of BDD often result in extreme social isolation, as patients tend to avoid social situations where others may notice the supposed defect. Patients are often housebound. They usually do not marry, are under- or unemployed, and are less likely to graduate from college. The morbidity and mortality associated with BDD is real. About 25% to 30% of patients will attempt suicide. Cotterill and Cunliffe found that most dermatologic patients who committed suicide were diagnosed with acne or BDD. Patients with BDD are also at increased risk for auto accidents from inattention, as well as injuries from self-performed corrective "surgery." Examples include using a staple gun to correct loose skin on the face, filing teeth to alter jawline appearance, and abrading skin with sandpaper to remove scars and lighten the complexion.
Paul avoided social situations and had only recently married. He had developed significant infections from picking at his neck.
Comorbidity And Differential Diagnosis
Most patients with BDD have at least 1 comorbid psychiatric disorder, such as depression, personality disorder (primarily cluster C), OCD, substance abuse, and social phobia. Usually, patients with BDD initially are diagnosed with a comorbid condition or misdiagnosed with a different disorder. Many patients with OCD will also meet criteria for BDD and vice versa. A patient with BDD whose obsessions focus only on appearance should not also be diagnosed with OCD. OCD, BDD, hypochondriasis, pathologic skin picking, somatoform disorders, and eating disorders are found in disproportionately higher numbers in relatives of patients with BDD. Unlike OCD, the preoccupations of BDD are ego-syntonic and not resisted. Some researchers view BDD as an obsessive-compulsive spectrum disorder. Social phobia and depressive symptoms are common in patients with BDD. When present, symptoms of social phobia usually precede BDD. Co-morbid depression usually begins within a year of BDD symptom onset and is often chronic. An additional diagnosis of delusional disorder, somatic type, may also be given if the preoccupation with appearance is of delusional intensity.
Eating disorders (EDO) and BDD are the only diagnoses in DSM characterized by a disturbed body image. While the severity of body image disturbance is equal in EDO and BDD, patients with an EDO have a more global focus. Some 11% of women with bulimia and 5% of women with anorexia nervosa also meet the criteria for BDD. If the patient has a specific appearance-related preoccupation (eg, nose too big), along with the general body image disturbance of an EDO (eg, body too fat), BDD may be diagnosed comorbid with the EDO.
Paul did not meet full DSM-IV criteria for anorexia nervosa, binge/purge subtype, as his weight was in normal range. He would meet criteria for EDO not otherwise specified because of his purging behaviors and excessive general concerns about gaining weight. He also obsessed about cleanliness and orderliness, and exhibited related compulsive behaviors, unrelated to those of the EDO and BDD, that would meet criteria for OCD. He was not diagnosed with social phobia or avoidant personality disorder, as his social avoidance behaviors resulted from BDD. He was also diagnosed with alcohol abuse. He would isolate and drink himself into a stupor up to 3 times a week to help put himself to sleep, resulting in missed appointments the following day.
- John, Don St.; Imagined Ugliness: Body Dysmorphic Disorder; Physician Assistant, 87507544, Jul2003, Vol. 27, Issue 7
The article above contains foundational information. Articles below contain optional updates.
Reflection Exercise #9
The preceding section contained information
regarding the diagnostic features of BDD. Write three
case study examples regarding how you might use the content of this section in
Online Continuing Education QUESTION 23
According to John, what is the best indicator that BDD may be present? Record the letter of the correct answer the .