AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

Body dysmorphic disorder (BDD) was recognized formally in 1997 in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) under the somatoform disorders. BDD is defined as a preoccupation with an imagined or slight defect in appearance. This preoccupation causes significant distress or impairment in social, occupational, or other areas of functioning in the person's life. Another disorder, such as whole body image dissatisfaction (as in anorexia nervosa), cannot explain this preoccupation.

In Europe more than 100 years ago, Morselli described persons with a subjective feeling of ugliness or with a slight physical defect considered abnormal by the patient but undetectable by others. He stated that these people felt miserable, were tormented by their imagined defect, and were consumed by thoughts of this defect in any situation. The term dysmorphobia was coined by him.

The facial area, including the skin, hair, or nose, are the most common area of concern for many patients. Many patients affected with BDD have comorbid conditions, such as obsessive-compulsive disorder (OCD), major depression, delusions, or social phobia. Of those with a primary diagnosis of BDD, 30% meet criteria for OCD. Approximately 2-7% of patients who undergo plastic surgery have BDD. Patients who undergo plastic surgery generally are unhappy with the results and find another part of the body with which to be concerned or continue to be consumed with thoughts about the postoperative site.

Pathophysiology

Social values greatly influence body image, an important part of self-image. The media projects the impression that certain norms exist in appearance. This often leads individuals to compare themselves to people in movies, on television, or in magazines.

There are also theories that the human brain might be hardwired for certain ideal kinds of faces, bodies, and postures. These may signal health and reproductive fitness. Scientists have found that infants prefer to gaze at faces that adults consider attractive. Most people have concerns related to appearance; however, it is considered pathologic when concern causes distress and interferes with social or occupational functioning.

BDD is an unhealthy preoccupation with a mild or imagined defect of the body. This preoccupation with a perceived deformity disrupts patients' lives. Those who are affected check their appearance in mirrors frequently to confirm or conceal their perceived deformity. They may engage in long rituals of grooming, such as repeatedly combing hair, applying makeup, or picking skin. Patients think that this behavior may reduce their level of anxiety; however, it only intensifies it.

Because of frequent comorbidity with several other conditions, the diagnosis of BDD is often overlooked in psychiatric settings and in medical and surgical settings. Thus, the clinician should ask specific questions about BDD. For example, in a study of 110 patients with BDD, 51% did not reveal their symptoms to their therapist. However, as Phillips and Kaye noted, the outcome of treatment with the same medications and continued investigation indicate that disorders such as OCD, eating disorders, and anxiety disorders might be linked physiologically.¹

Because patients with BDD have many features in common with OCD, BDD has often been included in the spectrum of OCD. Similarities include repetitive thoughts of a perceived defect that consumes most of the patient's time and activities centered on concealing or confirming the perceived deformity. BDD has much higher rates of poor insight, ideas of reference, overvalued ideas, and delusions. In a 2000 study, Deckersbach et al found that patients with BDD had impaired verbal and nonverbal memory encoding strategies.² This finding indicates that executive memory deficits occur, and a lesion of the frontostriatal connections is involved. This abnormality in memory encoding also occurs in patients with OCD, and both conditions respond best to high-dose selective serotonin reuptake inhibitors (SSRIs). Enlarged white matter volume and asymmetry of the caudate nucleus favoring the left have been observed in patients with BDD.

Some patients with BDD are noted to have a delusional component to their disease. Lack of insight characterizes the delusional variant of BDD. Patients with delusional BDD are the most severely dysfunctional These patients respond well to SSRIs, not antipsychotics.

Patients with BDD are more prone to major depression. In a 1999 report, Phillips et al noted that in clinical settings, 60% of patients with BDD have major depression and the lifetime risk for major depression in these patients is 80%.³ Patients with this comorbid duo are more at risk for suicide. Determining if patients with depression also have BDD is important because the treatment is more specific. Usually, major depression occurs as a result of the BDD, not vice-versa. Treatment for BDD is high-dose SSRIs, and patients who have major depression as a result of their BDD usually do not respond to non-SSRI medications or electroconvulsive therapy.

Social anxiety disorder is another common comorbid disorder found in those with BDD. This common and treatable anxiety disorder may be disabling if not treated.

Frequency

United States

BDD affects 1-2% of the general population; however, this is thought to be an underestimate because BDD frequently is underdiagnosed. Patients are ashamed of their problem and do not report it to their physicians. Incidence in the cosmetic surgery population ranges from 2-7%. Incidence in the dermatology population ranges from 9-15%.

International

Incidence and prevalence are unknown with any precision or accuracy.

Mortality/Morbidity

Patients with BDD often have low self-esteem and feel the need to confirm or avoid their perceived defect by engaging in ritualistic behaviors. These behaviors include checking their appearance in mirrors or avoiding mirrors, comparing their perceived defect with others, requiring constant reassurance from others that their defect is "normal" or "not that bad," and grooming excessively (eg, hair combing, applying makeup, picking skin). Patients with BDD often seek dermatologic or cosmetic referral for correction of their perceived defect.

• Patients generally engage in thoughts and behaviors relating to their perceived defect for 1 hour or more per day. In one series of adolescent patients, the average amount of time spent in activities related to their perceived defect was as much as 3 hours. These patients had particularly poor insight into their problem. Patients with poorer insight are likely to spend more time dealing with the imagined defect.
• Persons affected with BDD often avoid social situations because they fear people may point out their imagined defect or avoid them. Some patients skip school or work repeatedly or become housebound. They usually have difficulty maintaining relationships with peers, family, and spouses. Generally, persons affected with BDD are unmarried (three quarters of patients). Patients demonstrate a lack of effort in normal thinking because of obsessive concerns about their defect, causing them to have poor school or work performance.
• One of the most common comorbid conditions with BDD is major depression. Patients with these disorders usually have major depression as a result of BDD. These patients also are at increased risk for suicide; up to 29% of patients with BDD attempt suicide. Women with perceived facial defects are especially at risk for suicide. Therefore, inquiring about suicide risk is essential when working with patients with this disorder.

Race

No data are available on the relationship between BDD and race. However, one may speculate that cultures and groups with high emphasis on physical beauty and attractiveness may be more prone to having this disorder.

Sex

BDD affects men and women with equal frequency. Men are more likely to have a diagnosis of substance abuse (50%) and be single. Women more often have comorbid anxiety and panic disorder and are obsessed with legs and breasts.

Age

• The onset of BDD is in adolescence and young adulthood. As mentioned by Philips and Kaye, the average age of onset is 16-17 years.¹ As with OCD, the course of BDD is generally chronic.
• It may also occur in older adults who are overly concerned with their aging appearance.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

Elicit a history about BDD in patients who visit family practitioners, internal medicine physicians, dermatologists, or plastic surgeons. Patients describe facial or bodily features that they wish were changed. Frequently, patients ask for referral to a specialist to correct their imagined deformity and usually are ashamed to make the physician aware of how much time they spend dealing with their perceived defect. Generally, patients with BDD change doctors frequently and are unhappy with the results obtained by surgical or cosmetic procedures. This disorder frequently is underdiagnosed and not treated properly. If BDD is suspected, refer the patient to a psychiatrist, but be aware that some patients may be offended by this referral.

• The most common reason patients initially visit a physician is unhappiness about a facial feature or a feature on the genitals or body. The 3 most common sites patients are dissatisfied with are the following:
• • Skin - Acne, wrinkles, spots
  • Hair - Thinning, balding
  • Nose - Size, shape
• Other patients may be concerned with the following:
• • Penis (size)
  • Muscles
  • Breasts
  • Buttocks
• Many patients with BDD are preoccupied with more than 1 body part at a time.
• Asking the following questions may help determine if a patient has or is at risk for BDD:
• • Do you avoid social situations because of your bodily concern?
  • Do you feel this defect is causing you problems with your job or school?
  • Do you feel that this defect is causing you distress?
  • How much time do you spend in concealing your defect?
  • Do you feel this defect prevents you from developing a sexual relationship?
• If BDD or risk of BDD is suspected, refer the patient to a psychiatrist for evaluation and treatment.

Physical

Patients with BDD have either a normal appearance or a slight defect of the concerned body part. Patients may appear anxious or depressed.

Because this is a complex psychiatric illness, a mental status examination should be performed. The clinician should especially ask questions about depression, suicidal ideation, and anxiety. Organic factors should be excluded by exploring orientation, memory, and ability to concentrate.

Causes

The causes of BDD are not yet known. However, increasing evidence shows that genetic links may be involved. Preliminary results from John Hopkins University's OCD Family Study indicate a first-degree relationship between BDD and OCD.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

Normal concerns about appearance
Major depressive disorder
Avoidant personality disorder
Narcissistic personality disorder
Sexual identity disorder

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Tests

• The Multidimensional Body-Self Relations Questionnaire is a self-reported measure of body image. It assesses satisfaction with appearance and preoccupation with perceived defects. This is used in clinical trails and may not be practical in routine office settings.
• The Body Dysmorphic Disorder Examination Self-Report measures the dissatisfaction the patient has related to the perceived defect. This is another tool used in clinical trials and may not be practical in routine office settings.
• Mental Status Examination
• • In the typical mental status, the nondelusional patient displays little or no insight. For a brief time they may admit that they might be wrong about their preoccupation. They have often only come to the psychiatrist because they were coerced by a family member or because it was ordered by the plastic surgeon.
  • A delusion is a false belief that a person cannot be talked out of, even with adequate proof. The delusional patient with BDD may believe that what they believe as their abnormal body part is slowly worsening or that other people are always staring or know about it.
  • The remainder of the mental status examination is usually within normal limits except for the amount of time and energy spent on the preoccupation. Auditory hallucinations or wide mood swings might point to additional diagnoses such as schizophrenia or bipolar disorder.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical Care

• The mainstays of treatment for BDD are SSRIs. However, these agents are not approved by the Food and Drug Administration for treatment of BDD.
• • Several studies have been conducted on small groups of patients and appear to establish the superiority of SSRIs. Recent FDA warnings regarding all antidepressents warrant close observation for increased depressive symptoms and/or suicidal ideation, particularly at the onset of therapy.
  • Other pharmacologic agents, such as neuroleptics, trazodone, lithium, benzodiazepines, tricyclics (excluding clomipramine), and anticonvulsants have been much less beneficial or have been ineffective.
  • In general, higher SSRI doses than those prescribed for depression appear to be needed. This is similar to the treatment of OCD. A 1999 review article by Phillips points out that most SSRI studies for BDD have a mean time to treatment response of 6-16 weeks.
  • Examples of SSRIs include Prozac (40-80 mg/d), Paxil (40-60 mg/d), Luvox (200-300 mg/d), and Zoloft (200 mg/d).
  • SSRIs have proven effective for patients who have delusional beliefs, even without the use of neuroleptics.
• Psychotherapy, especially cognitive-behavioral psychotherapy, or behavioral modification therapy are highly recommended additions to treatment with SSRIs.
• • Approaches include systematic desensitization, exposure techniques, self-confrontational techniques, and cognitive imagery.
  • A few studies have claimed successful results with behavior modification alone.
• Strongly consider therapy with family members, spouses, or significant others to help improve the patient's outcome.
• • People who have a close relationship with the patient may agree with the patient's perception of the defect and may reinforce the patient's maladaptive beliefs and behaviors.
  • On the other hand, people with a close relationship to the patient may disagree with what the patient thinks is necessary for treatment.

Surgical Care

• Many patients with BDD seek consultations with dermatologists and cosmetic surgeons.
• • Cosmetic surgery may have potential benefits or no benefits at all. In 1998, Sarwer et al found that some patients with this disorder might have an exacerbation of symptoms following plastic surgery.²⁹ Some people with BDD later switch the focus of their concern to other features of their appearance.
  • Patients with BDD have been described as the most difficult patients for dermatologists and plastic surgeons to treat. They often insist on repeated procedures and require the specialist's reassurance. Despite the physician's efforts, patients with BDD are not able to believe that further intervention is not necessary. These patients have been known to initiate lawsuits because of unsatisfactory results. Paranoid personality disorder (individuals who can often be litigious) is not an infrequent comorbidity.
  • The astute plastic surgeon seeks a psychiatric consultation and works with the psychiatrist before and after surgery to promote a reasonable patient attitude or to recommend against surgery.

Consultations

• Patients diagnosed with BDD should receive consultation with a psychiatrist or psychologist. Appropriate circumstances may exist in which the patient's psychiatrist or therapist may refer the patient for cosmetic, surgical, or dermatological diagnosis.
• A specialist should rule out actual physical pathology if any doubt exists about the person's deformity.

Diet

No know relevance

Activity

No known relevance

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

The goals of pharmacotherapy are to reduce morbidity and to prevent complications.

Drug Category: Selective serotonin reuptake inhibitors

Potentiate the pharmacological effects of serotonin (5-HT) in the CNS.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Outpatient Care

BDD is considered a chronic condition and requires maintenance therapy and regulation of SSRIs. The American Psychiatric Association recommends seeing patients who are taking maintenance medications a minimum of 3-4 times per year. Approximately 53% of those with BDD experience relapse within 6 months of discontinuation of treatment.

In/Out Patient Meds

To treat a chronic disorder such as BDD, prescribing the same dosages of medications for initial treatment and ongoing maintenance is usually considered prudent. The concept of lower maintenance dosages is less valid because more studies support higher relapse rates at lower maintenance dosages.

Complications

Some patients who are not treated may become delusional or may become increasingly depressed or suicidal. Moreover, when treating a person with this disorder, challenging or working with the delusion can make that individual more depressed.

Prognosis

• The prognosis generally is good with full and appropriate treatment with both medication and psychotherapy.
• The presence of a delusional intensity of belief or comorbid conditions may require more extensive and intensive therapy and follow-up.

Patient Education

• The cognitive-behavioral psychotherapy and behavioral modification approaches include significant patient education. As noted above, education of family members also is valuable.
• For excellent patient education resources, visit eMedicine's Eating Disorders Center and Depression Center. Also, see eMedicine's patient education articles Anorexia Nervosa and Depression.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

Patients frequently consult cosmetic specialists (eg, dermatologists, plastic surgeons). These patients tend to be unhappy with the results of the procedure.

• Patients with BDD generally become focused on the original perceived defect or find a new one with which to be concerned, including any surgical blemishes or scars.
• Thoroughly document and discuss treatment with patients in suspected cases of BDD. For planned surgical changes, a presurgery psychiatric consultation might be protective.

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

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Article Last Updated: Aug 20, 2007