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) is a type of somatoform disorder characterized by a patient's persistent and unremitting preoccupation with an imagined defect in appearance (eg, a large nose) or an exaggerated sense of the severity of a perceived physical flaw. According to the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV), this excessive preoccupation results in notable emotional distress and impairment in function at school, work, or home or during other important life functions.¹

Patients with BDD seek actions, such as cosmetic surgery, to correct their perceived malformation. Patients with symptoms exclusively focused on a preoccupation with body weight and shape or perceived inappropriateness of sexual characteristics are not diagnosed with BDD and frequently meet criteria for other disorders such as anorexia nervosa or gender identity disorder.

Parents of children with BDD may seek psychiatric evaluation after witnessing excessive mirror checking, time-consuming grooming, and an inability to be reassured about the perceived flaw. From a developmental perspective, some preoccupation with appearance is common during adolescence; however, adolescents with BDD exhibit clinically significant distress or impairment in functioning. People with BDD are often involved in costly and potentially dangerous cosmetic surgeries and dermatological treatments, often in futile efforts to correct their perceived intolerable physical flaws.

Pathophysiology

The pathophysiology of BDD is still unknown, although numerous theories have been suggested.² The neurobiology of BDD is only now under investigation. Evidence from demographic features, phenomenology, course, and treatment response suggest BDD may be related to obsessive-compulsive disorder (OCD), and the pathophysiology may involve serotonin.³

Sociologically speaking, BDD has been explained as an excessive interpretation of society's ideals of physical beauty and an overvaluing of available cosmetic procedures to correct perceived flaws. Patients with BDD are often insecure, sensitive, obsessional, schizoid, anxious, narcissistic, and introverted and have hypochondriac traits. Because BDD has a strong association with hypochondriasis and other conditions that involve obsessional thoughts, using a neurobiologic approach, BDD is believed to preferentially respond to selective serotonin reuptake inhibitors (SSRIs). Some evidence indicates that BDD and other OCDs may be aggravated by m-chlorophenylpiperazine, a partial serotonin agonist.

Frequency

United States

An estimated 1% of the population is affected by BDD.⁴ No epidemiologic data are currently available for BDD in children and adolescents.

International

In cosmetic surgery and dermatology settings, 6-15% of patients are estimated to have BDD. No epidemiologic data are currently available for BDD in children and adolescents.

Patients who undergo cosmetic surgery do not seem to have increased incidence of generalized body dissatisfaction; however, when surveyed about specific body parts, they have a much higher incidence of specific body part dissatisfaction.⁵

Mortality/Morbidity

Phillips et al (1995) have reported a virtual absence of psychiatric literature on BDD in children and adolescents despite preliminary evidence suggesting that the onset of BDD occurs in adolescence.³ They studied functional impairment in 130 patients with BDD. The findings were as follows:

• Social dysfunction: Thirty-two percent of patients had been housebound at least for a week because of their symptoms. Ninety-eight percent of individuals in the group had significant impairment in social functioning. Seventy-four percent of patients had impairments in academic or occupational functioning. Thirteen percent of affected individuals had received government disability payments because of BDD.
• Suicide risk: A distinct risk of suicide is observed, especially in women. Twenty-nine percent of the BDD group studied made at least one suicide attempt. Sixty percent of these attempts were due to BDD symptoms.

Race

No racial predilection is known.

Sex

The sex distribution of BDD is not known. In males, the preoccupation is often related to obsessions about genitalia. Women with BDD are often preoccupied with their hair, face, and breasts.

Age

BDD generally starts during adolescence and is usually continuous over time, with waxing and waning symptoms. For many patients, it becomes chronic. The body part that is the focus of concern may remain the same or may change over time.

CLINICAL

Section 3 of 10  

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

History

• Natural history
• • Body dysmorphic disorder (BDD) is a chronic disorder that can wax and wane in intensity.
  • The symptoms often start during adolescence. Over the course of a lifetime, new symptoms may be added onto the original presentation or symptoms may shift from one body part to another.
  • BDD may not be diagnosed for many years after its onset, often because of the patient's reluctance to reveal the symptoms. In some cases, patients who are ashamed of their symptoms may not identify individual symptoms, referring only to a sense of general ugliness.
• Behavior
• • BDD may lead to time-consuming unproductive rumination. Patients adopt repetitive, obsessive, and ritualistic behavior and may spend most of their time in front of a mirror, repeatedly checking their perceived imperfections.
  • BDD is associated with significant social impairment ranging from diminished social activities to extreme social isolation. In severe cases, individuals may leave home only at night and avoid job interviews, dating, and peers.
  • Patients also have a constant need for reassurance about their perceived flaws and can often be extremely demanding to primary care physicians and cosmetic surgeons in their pursuit of perfection.
• Common areas of perceived imperfections
• • Skin
  • Face
  • Nose
  • Mouth
  • Hair
  • Eyelids
  • Wrinkles
  • Excessive greasiness
  • Acne
  • Excessive facial hair
  • Nasal size and shape
  • Teeth
  • Bite of jaw
  • Breasts
  • Genitals
  • Buttocks
  • Lips

Physical

Patients with BDD often have no distinguishing physical or dermatologic findings.

Causes

Causes are unknown at this time.

DIFFERENTIALS

Section 4 of 10  

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

WORKUP

Section 5 of 10  

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

Lab Studies

No specific laboratory tests are used to diagnose body dysmorphic disorder (BDD).

Imaging Studies

No specific imaging studies are used to diagnose BDD.

TREATMENT

Section 6 of 10  

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

Medical Care

Treatment of body dysmorphic disorder (BDD) may include cognitive-behavioral psychotherapy, pharmacologic interventions, and other psychosocial interventions that promote social functioning.

• Treatment goals
• • To prevent adoption of the sick role
  • To minimize unnecessary costs and complications by avoiding unwarranted hospitalizations, diagnostic and treatment procedures, medications, and especially corrective surgeries (Patients with BDD are generally not satisfied with the results of corrective surgery; in some cases, obsessions intensify after such a treatment.)
  • To achieve pharmacologic control of comorbid syndromes and BDD
• Psychotherapy and psychosocial strategies and techniques
• • Consistent treatment, generally by the same physician
  • Supportive office visits scheduled at regular intervals
  • Focus gradually shifted from symptoms to personal and social problems
  • Cognitive-behavioral therapy involving prevention of body inspection rituals and reassurance seeking⁶
• Pharmacologic and physical strategies and techniques
• • Avoid drugs with abuse or addictive potential.
  • SSRIs may be helpful in controlling obsessional thinking. Clomipramine is another option.

Consultations

A psychiatrist should be consulted to aid with medications and behavioral therapy.

MEDICATION

Section 7 of 10  

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

In recent years, SSRIs have appeared to be useful in the treatment of body dysmorphic disorder (BDD). Other classes of drugs, including tricyclic antidepressants (TCAs), benzodiazepines, neuroleptics, and anticonvulsants, have produced minimal or no improvement. In general, medication use is recommended in conjunction with psychosocial interventions such as cognitive-behavioral therapy.

Drug Category: Selective serotonin reuptake inhibitors (SSRIs)

These agents are used in the treatment of BDD. They are antidepressant agents that are chemically unrelated to the tricyclic, tetracyclic, or other available antidepressants. They inhibit CNS neuronal uptake of serotonin (5HT). They may have a weak effect on norepinephrine and dopamine neuronal reuptake and have been used to treat patients with anxiety, phobias, or OCDs.

SSRIs are greatly preferred over the other classes of antidepressants. Because the adverse effect profile of SSRIs is less prominent, improved compliance is promoted. SSRIs do not have the cardiac arrhythmia risk associated with TCAs. Arrhythmia risk is especially pertinent in overdose, and suicide risk must always be considered when treating a child or adolescent with mood disorder.

Physicians are advised to be aware of the following information and use appropriate caution when considering treatment with SSRIs in the pediatric population.

In December 2003, the UK Medicines and Healthcare Products Regulatory Agency (MHRA) issued an advisory that most SSRIs are not suitable for use by persons younger than 18 years for treatment of "depressive illness." After review, this agency decided that the risks to pediatric patients outweigh the benefits of treatment with SSRIs, except fluoxetine (Prozac), which appears to have a positive risk-benefit ratio in the treatment of depressive illness in patients younger than 18 years.

In October 2003, the US Food and Drug Administration (FDA) issued a public health advisory regarding reports of suicidality in pediatric patients being treated with antidepressant medications for major depressive disorder. This advisory reported suicidality (both ideation and attempts) in clinical trials of various antidepressant drugs in pediatric patients. The FDA has asked that additional studies be performed because suicidality occurred in both treated and untreated patients with major depression and thus could not be definitively linked to drug treatment.

However, a recent study of more than 65,000 children and adults treated for depression between 1992 and 2002 by the Group Health Cooperative in Seattle found that suicide risk declines, not rises, with the use of antidepressants.⁷ This is the largest study to date to address this issue.

Currently, no evidence associates OCD and other anxiety disorders treated with SSRIs with an increased risk of suicide.

Drug Category: Tricyclic antidepressant agents (TCAs)

These agents are used when SSRIs are ineffective. They are structurally related to the phenothiazine antipsychotic agents and exhibit 3 major pharmacologic actions in varying degrees (ie, amine pump inhibition, sedation, anticholinergic action [peripheral and central]). They inhibit reuptake of norepinephrine or serotonin (ie, 5-hydroxytryptamine, 5-HT) at the presynaptic neuron.

Physicians should be cautious when using this particular class of medication because overdose has the potential to be deadly. Patients with BDD may have higher risk of suicidal behavior; thus, the potential harm to the patient in an overdose situation should be considered when choosing the type of antidepressant.

FOLLOW-UP

Section 8 of 10  

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

Further Outpatient Care

• Patients have best results when treated by a consistent medical and mental health team.
• Cognitive-behavioral therapy may be beneficial in situations during which patients develop a structured and predictable strategy in order to identify cognitive errors and maladaptive thinking.
• When cognitive-behavioral therapy is efficacious, patients learn to alter cognitive distortions and are able to maintain and generalize more adaptive thought patterns in daily life.

In/Out Patient Meds

• Patients may benefit most from a combination of SSRIs in conjunction with therapy sessions. Maximum benefit of SSRI medication may take several months.

Complications

• Practitioners must be made aware that patients with body dysmorphic disorder (BDD) are at a higher risk for suicide.

Prognosis

• BDD is a chronic disease, and the goal of therapy is to keep symptoms controlled.

MISCELLANEOUS

Section 9 of 10  

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

Medical/Legal Pitfalls

• Body dysmorphic disorder (BDD) is sometimes overlooked as a diagnosis because many patients are reticent about discussing their symptoms. Failure to make this diagnosis can be dangerous because these patients are at increased risk for suicide.
• Patients with BDD are also at risk for repeated cosmetic surgery to correct their perceived, but nonexistent, problem.

REFERENCES

Section 10 of 10

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

1. APA. Diagnostic and Statistical Manual of Mental Disorders. 4^th ed. Washington, DC: American Psychiatric Association; 1994.
2. Allen A, Hollander E. Body dysmorphic disorder. Psychiatr Clin North Am. Sep 2000;23(3):617-28. [Medline].
3. Phillips KA, Atala KD, Albertini RS. Case study: body dysmorphic disorder in adolescents. J Am Acad Child Adolesc Psychiatry. Sep 1995;34(9):1216-20. [Medline].
4. Cotterill JA. Body dysmorphic disorder. Dermatol Clin. Jul 1996;14(3):457-63. [Medline].
5. Sarwer DB, Wadden TA, Pertschuk MJ, Whitaker LA. Body image dissatisfaction and body dysmorphic disorder in 100 cosmetic surgery patients. Plast Reconstr Surg. May 1998;101(6):1644-9. [Medline].
6. Neziroglu F, Hsia C, Yaryura-Tobias JA. Behavioral, cognitive, and family therapy for obsessive-compulsive and related disorders. Psychiatr Clin North Am. Sep 2000;23(3):657-70. [Medline].
7. Simon GE, Savarino J, Operskalski B, Wang PS. Suicide risk during antidepressant treatment. Am J Psychiatry. Jan 2006;163(1):41-7. [Medline]. [Full Text].
8. Fritz GK, Fritsch S, Hagino O. Somatoform disorders in children and adolescents: a review of the past 10 years. J Am Acad Child Adolesc Psychiatry. Oct 1997;36(10):1329-38. [Medline].
9. Siberry GK, Iannone R, eds. The Harriet Lane Handbook. 15^th ed. St. Louis, Mo: Mosby-Year Book; 2000:615-891.
10. Tasman A, Jerald K, Lieberman J, eds. Body dysmorphic disorder. In: Psychiatry. Philadelphia, Pa: WB Saunders Co; 1997:1148-51.

Article Last Updated: Mar 17, 2008