A. Preoccupation with an imagined defect in appearance. If slight physical anomaly is present, the person’s concern is markedly excessive.
B. The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
C. The preoccupation is not better accounted for by another mental disorder (e.g., dissatisfaction with body shape and size in Anorexia Nervosa).
- BDD has a delusional form that is classified in the psychosis section of DSM-IV (Didie, Kelly, & Phillips, 2010).
Barlow and Durand (2009) give an example of BDD:
In his mid-20s, Jim was diagnosed with suspected social phobia; he was referred to our clinic by another professional. Jim had just finished rabbinical school and had been offered a position at a synagogue in a nearby city. However, he found himself unable to accept because of marked social difficulties. Lately he had given up leaving his small apartment for fear of running into people he knew and being forced to stop and interact with them.
Jim was a good-looking young man of about average height, with dark hair and eyes. Although he was somewhat depressed, a mental status exam and a brief interview focusing on current functioning and past history did not reveal any remarkable problems. There was no sign of a psychotic process (he was not out of touch with reality). We then focused on Jim’s social difficulties. We expected the usual kinds of anxiety about interacting with people or “doing something” (performing) in front of them. But this was not JIm’s concern. Rather, he was convinced that everyone, even his good friends, were staring at a part of his body that he found grotesque. He reported that strangers would never mention his deformity and his friends felt too sorry for him to mention it. Jim thought his head was square! Like the Beast in Beauty and the Beast who could not imagine people reacting to him with anything less than revulsion, Jim could not imagine people getting past his square head. To hide his condition as well as he could, Jim wore soft floppy hats and was most comfortable in winter, when he could all but completely cover his head with a large stocking cap. To us, Jim looked normal.
Activities associated with preoccupations include:
- Obsessions in: grooming; mirror checking, hair brushing, hair styling, hair cutting, shaving, washing, and application of makeup.
- Camouflaging: wearing wigs, hats, make-up, sunglasses, extra clothing and changing body position to hide perceived defect.
- Medical procedures: numerous dermatological visits, and multiple cosmetic surgeries. Need for reassurance: mirror checking, asking others opinion, and excessive comparison to other people. Diet and exercise: excessive exercise, muscle dysmorphia, steroid usage; excessive diet, anorexia nervosa, and bulimia nervosa (eating disorders).
- The most common preoccupations of the body focus primarily on the skin, hair, and nose. People diagnosed with BDD typically have poor self-image/esteem, express shame in appearance, feel ugly, unlovable, and have a strong fear of rejection. Many patients with BDD believe that their deformities make them unacceptable as a person (Didie et al., 2010). Suicide idealization, attempts, and completion are significantly high in comparison to other mental disorders; however, the studies are few and only preliminary. Reasons for results suggest that suicidal risk is higher in patients with BDD. High suicidal risks are due to high rates of psychiatric hospitalization, comorbidity prevalence, being single and divorced, low self-esteem, poor social support, and having high levels of anxiety, depression, and hostility. Suicide attempts are as high as 24%-28% with ideation as high as 78%-81% (Didie et al., 2010). BDD lifetime rate of suicide attempts is an estimated 5.2 times higher than in the general U.S. adolescent population (Phillips, Didie, Menard, Pagano, Fay, & Weisberg, 2006).
- BDD preoccupations are time-consuming, occurring on average 3 to 8 hours per day (Didie et al., 2010).
Child vs. adult presentation
Most research suggests that the onset of BDD begins in early adolescents, although, little research has been done regarding definite onset. The role of body image during pubertal change increases body focus and dissatisfaction. Adolescents typically present more often with body shape and weight concerns related to distress, as opposed to adult presentation of dissatisfaction of specific body parts (i.e., face and hair).
In general adolescents and adults do not differ significantly on most characteristics (Phillips et al., 2006).
Gender and cultural differences in presentation
Most research suggest BDD in non-discriminative across gender lines. Some research suggests females are more likely to present associated features resembling weight and shape concerns, eating disorders, and depressive disorders. Sociocultural influences include appearance related pressures. Socially constructed conceptions of perfection and/or beauty portrayed through the media affect both genders without bias. BDD exists in many cultures around the world. The areas having the most research conducted include the United States, Italy, and the United Kingdom. Studies pertaining to prevalence rates cross-cultures have been insignificant in number; the studies suggest prevalence rate to be very similar.
- BDD is relatively common with prevalence rates from 0.7% to 2.4% in the general population (Didie et al., 2010).
- Prevalence rates tend to increase in clinical settings. Prevalence rates in the medical population of dermatology increase to 9%-12%, and in the cosmetic surgery population, an increase of 3%-53% (Didie et al., 2010).
- BDD is relatively common in outpatients with OCD (8% to 37%); social phobia (11% to 13%); trichotillomania (26%); and atypical major depressive disorder (14% to 42%) (Didie et al., 2010).
Body Dysmorphic Disorder usually begins during adolescence but can begin during childhood. About 70% of patient’s experience onset of BDD before 18 years (Didie et al., 2010). The disorder is more commonly chronic and unremitting than it is not. Suicidal have higher rates for this disorder than other mental disorders.
The disorder may not be diagnosed for many years, often because Individuals with the disorder are reluctant to reveal their symptoms. The onset may be gradual or abrupt, and the disorder has a continuous course, with few intervals that are symptom-free, although the intensity of the symptoms may fluctuate over time.
People suffering with BDD typically present to cosmetic surgeons for correction of perceived bodily flaw, and inevitably receive no satisfaction or relief from disorder.
Serotonin deregulation seems to be common among patients with BDD. Selective serotonin reuptake inhibitor (SSRI) (i.e., fluoxetine hydrochloride, otherwise known as Prozac) drugs have been empirically proven to decrease the symptoms associated with BDD. Another empirically supported approach is cognitive behavioral therapy (CBT). A combination of SSRI and CBT is the common approach to BDD.
The key to successful CBT for BDD is engagement of the patient (Veale, 2010).
Behavioral and/or cognitive-behavioral techniques are typically used to change abnormal activities like avoidance behavior, reassurance seeking, checking, and excessive grooming. For example, exposure in vivo can be used to help people with BDD become more comfortable exposing themselves to social situations.
It is recommended that individuals with mild BDD are offered CBT that is specific for BDD or guided self-help based on CBT (Veale, 2010).
Individuals with BDD with sever functional impairment should be offered combined treatment with an SRI and CBT (Veale, 2010).
Another treatment that is sort of under the radar is the idea of plastic surgery. Almost 50% of people with BDD go “under the knife” to correct what they have a problem with on their body too.
- Major depressive disorder is the most common comorbid disorder in patients with BDD, with social phobia and OCD the next common (Didie et al., 2010).
- Lifetime rates of substance abuse disorders are 36% to 48%, with 30% of individuals with BDD having comorbid lifetime substance abuse and 36% having comorbid lifetime substance dependence (Didie et al., 2010).
DSM-V recommended revisions www.dsm5.org
#1: Clarify the criterion’s meaning and aim to make it more acceptable to patients.
#2: Add examples to increase awareness of some of the common types of distress or impairment in functioning.
#3: Limit criterion to eating disorders.
The work group is recommending that this disorder be reclassified from Somatoform Disorders to Anxiety and Obsessive-Compulsive Spectrum Disorders
- A. Preoccupation with a perceived defect(s) or flaw(s) in physical appearance that is not observable or appears slight to others.
- B. At some point during the course of the disorder, the person has performed repetitive behaviors (e.g., mirror checking, excessive grooming, skin picking, or reassurance seeking) or mental acts (e.g., comparing their appearance with that of others) in response to the appearance concerns.
- C. The preoccupation causes clinically significant distress (for example, depressed mood, anxiety, shame) or impairment in social, occupational, or other important areas of functioning (for example, school, relationships, household).
- D. The appearance preoccupations are not restricted to concerns with body fat or weight in an eating disorder.
- Muscle dysmorphia form of body dysmorphic disorder (the belief that one’s body build is too small or is insufficiently muscular)
- Specify whether BDD beliefs are currently characterized by:
- Good or fair insight: Recognizes that BDD beliefs are definitely or probably not true, or that they may or may not be true
- Poor insight: Thinks BDD beliefs are probably true
- Absent insight (i.e., delusional beliefs about appearance): Completely convinced BDD beliefs are true