What is body dysmorphic disorder?

Quick Answer
A psychiatric somatoform disorder resulting in exaggerated preoccupation with an imagined or minor defect in physical appearance that causes significant impairment of social functioning.
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Causes and Symptoms

Body dysmorphic disorder (BDD) may be related to, though distinct from, other psychiatric disorders such as obsessive-compulsive disorder, eating disorders, and depression. No definitive cause has been identified, though proposed models suggest an interaction of societal overemphasis on physical appearance, low self-esteem, and brain neurotransmitter abnormalities. There is increasing evidence of a genetic predisposition to anxiety-related disorders.

Patients have an overblown concern about one or more perceived body defects, commonly of the face, hair, or skin. Some patients may fixate on muscles, penis, breasts, or buttocks. Individuals suffer extreme distress as a result, which interferes with social and occupational functioning. Diagnostic criteria determined by the American Psychiatric Association include preoccupation with an imagined or minor defect in physical appearance that causes significant interruption of social functioning and is not explained by another mental disorder, such as anorexia nervosa.

Patients are often embarrassed or ashamed of the problem. They may become housebound and have difficulty maintaining interpersonal relationships. They may spend hours each day checking their appearance in mirrors and attempting to correct or hide the defect with excessive grooming rituals. Poor school and job performance are common, and approximately three-quarters of patients are unmarried.

Sufferers will often seek help from plastic surgeons or dermatologists to correct their perceived defect. This approach is most often unsuccessful, as the change in appearance is rarely enough to satisfy the patient. This may lead to repeated attempts at corrective surgery, which continue to result in disappointment, as they address only a symptom rather than the underlying disordered thinking.

Approximately 1 percent of the general adult population is thought to suffer from body dysmorphic disorder, with men and women being equally affected. The typical onset is in late adolescence or early adulthood. Patients are at increased risk for major depression. It is estimated that 60 percent of these patients also suffer from depression, and this combination places them at significant risk of suicide. Coexisting obsessive-compulsive disorder is also common.

Treatment and Therapy

The disorder is not uncommon, but it is frequently missed or misdiagnosed. Patients are most likely to be identified during visits to family practitioners, internists, dermatologists, or plastic surgeons where they describe physical features that they wish to change. Often they are seeking referral to a specialist for correction of the imagined defect.

When BDD is suspected, referral to a psychiatrist for evaluation and treatment is most appropriate. Definitive treatment is unknown, but pharmacologic treatment with high-dose selective serotonin reuptake inhibitors (SSRIs) combined with nonpharmacologic cognitive behavior psychotherapy is the most effective approach currently. It is important to avoid attempted cosmetic correction, which does not treat the underlying disorder and is rarely effective.

SSRIs are thought to reduce symptoms by regulating neurotransmitters in the brain. Their use has been shown to decrease the frequency of disturbing thoughts and ritualistic behaviors related to the perceived physical flaw. This treatment is more effective when combined with cognitive behavior psychotherapy to address the patient’s low self-esteem and negative body image. Therapy that educates and includes family members, spouses, and other close individuals may improve outcome.

Body dysmorphic disorder is typically a chronic condition requiring ongoing care. Relapse following discontinuation of therapy is common. The prognosis is good with continued treatment and follow-up.

Perspective and Prospects

Italian physician Enrique Morselli coined the term dysmorphobia in 1891 to describe patients who were tortured by their fear of an imagined physical deformity that was not noticeable to others. The condition was recognized by the American Psychiatric Association in 1987, renamed body dysmorphic disorder, and classified as a distinct somatoform disorder in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV; 1994). Among other updates, the DSM-5, published in 2013, adds the diagnostic criterion of repetitive behavior, feelings, or thoughts in response to a preoccupation with a perceived flaw.

The disorder has received significant attention and is now the subject of ongoing clinical research. Additional data are needed to pinpoint causes and evaluate new treatment approaches.

Bibliography:

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-5. 5th ed. Arlington, Va.: Author, 2013.

American Psychiatric Association. "Highlights of Changes from DSM-IV-TR to DSM-5." Arlington, Va.: Author, 2013.

Anxiety and Depression Association of America. "Body Dysmorphic Disorder (BDD)." ADAA, 2010–13.

Hunt, T. J. “The Mirror Lies: Body Dysmorphic Disorder.” American Family Physician 104.7 (July, 2008): 1204–17.

Phillips, K. A. The Broken Mirror: Understanding and Treating Body Dysmorphic Disorder. New York: Oxford UP, 2005.

Slaughter J. R., and A. M. Sun. “In Pursuit of Perfection: A Primary Care Physician’s Guide to Body Dysmorphic Disorder.” American Family Physician 60.6 (October, 1999): 1738–42.

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