Body Dysmorphic Disorder Clinical Presentation
- Author: Iqbal Ahmed, MBBS, FRCPsych(UK); Chief Editor: David Bienenfeld, MD more...
The fundamental issue in body dysmorphic disorder (BDD) is a preoccupation with an imagined defect in appearance or disproportionate concern with a slight physical anomaly. Common areas of perceived imperfections include the following:
Excessive facial hair
Nasal size and shape
Bite of jaw
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.
BDD may lead to time-consuming unproductive rumination. Patients adopt repetitive, obsessive, and ritualistic behavior and may spend a great deal of time in front of a mirror, repeatedly checking their perceived imperfections or engaging in exorbitant grooming or skin picking. Many people with BDD go to great lengths to conceal their imagined defects, using items such as wigs, hats, and makeup.
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 may avoid job interviews, dating, and peers.
Patients also have a constant need for reassurance about their perceived flaws and can often be extremely demanding of caregivers in their pursuit of perfection. Multiple visits, with resulting unsuccessful treatment, are common. Attempts to explain that the physical defect is either nonexistent or minor will be futile; individuals with BDD will continue to agonize over perceived flaws.
Because of the nature of the symptoms and the perceived solution, patients with BDD commonly present to a plastic or cosmetic surgeon. In such cases, it is critical that the surgeon elicit an appropriate history and consider referral to a psychiatrist. Most of these patients will not consider the possibility that the cause is perception-based and thus more amenable to psychiatric treatment than to surgical treatment; therefore, the referring physician must exercise sensitivity and empathy when making the referral.
Framing the psychiatric referral in the context of standard procedures, as is done with the psychological workup required as part of many elective bariatric procedures, may increase the likelihood that that patient will follow through with the referral, decrease the likelihood that the patient will be disappointed with the referring physician, and possibly decrease the likelihood that the patient will engage in surgeon-shopping.
Screening, identifying, and referring patients with BDD is particularly critical when physicians consider that patients with BDD who undergo corrective surgical procedures are typically unsatisfied with the results and often present with new complaints related to perceived defects ensuing from surgery. Some of these patients become both litigious and violent.
A thorough history focused on symptoms pertinent to BDD is the most reliable clinical tool for making an accurate diagnosis. Several surveys and scales have been developed that can be used to facilitate the process. One such scale, first published in 1997 by Phillips et al, is the Yale-Brown Obsessive Compulsive Scale Modified for Body Dysmorphic Disorder (BDD-YBOCS). This survey is a 12-item semistructured clinician-administered tool that has consistently been shown to be a reliable and valid measure of BDD severity.
In the course of interviewing a patient with BDD, a clinical picture will emerge that illustrates many of the following behaviors:
Patients with BDD feel compelled to engage in ritualistic behaviors to confirm the perceived defect or avoid its recognition by others; such behaviors include compulsive mirror checking, compulsive mirror avoidance, compulsive grooming (eg, hair combing, hair plucking, picking skin, or applying makeup), and repetitively comparing the perceived defect with the bodies of others
Some BDD patients require constant reassurance from others that their defect is “normal” or “not that bad”
Patients typically spend 1 hour or more—sometimes as much as 8 hours—daily on thoughts and behaviors relating to the perceived defect; patients with poorer insight are likely to spend more time dealing with the imagined defect
Patients often seek repeated dermatologic or cosmetic referral for correction of the perceived defect
Patients with BDD tend to find social situations difficult because they fear that people may point out their imagined defect or avoid them. They usually have difficulty maintaining relationships with peers, family, and spouses. Some patients skip school or work repeatedly. Many become housebound: About 30% of BDD patients have been housebound at some point for at least 1 week because of their preoccupation.
Asking the following 4 questions can quickly help clinicians screen for the presence of symptoms pertinent to BDD:
Are you worried about how you look? (Yes/No); if you are, do you think about your appearance problems a lot and wish you could think about them less? (Yes/No)
How much time per day, on average, do you spend thinking about how you look? - (a) Less than 1 hour a day; (b) 1-3 hours a day; (c) more than 3 hours a day
Is your main concern with how you look that you aren’t thin enough or that you might become too fat? (Yes/No)
How has this problem with how you look affected your life? - (a) Has it often upset you a lot? (Yes/No); (b) has it often gotten in the way of doing things with friends, your family, or dating? (Yes/No); (c) has it caused you any problems with school or work? (Yes/No); (d) are there things you avoid because of how you look? (Yes/No)
Question 1 - Answer of “yes” to both parts of the question
Question 2 - Answer of (b) or (c)
Question 3 - Whereas an answer of “yes” answer may indicate that BDD is present, it is possible that an eating disorder is a more accurate diagnosis
Question 4 - Answer of “yes” to any of the 4 parts of the question
Any body part can be a source of distress in a patient with BDD; however, the body areas noted most frequently are the skin, hair, and nose. Complaints vary widely, including preoccupation with wrinkles, spots, acne, and large pores. Women may be distressed by the appearance or function of their genitalia. The Cosmetic Procedures Screening questionnaire may be helpful in identifying women with BDD among those seeking labioplasty.
Vascular markings, greasiness, scars, paleness, redness, excessive hairiness, and thinning of hair are also common complaints. Folliculitis and scarring may be a product of skin picking and plucking of nonexistent hairs; these often result in exacerbation of distress.
With regard to physical examination, however, the signal characteristic of BDD is the paucity of physical findings in comparison with the patient’s complaint regarding the perceived physical defect. As in other psychiatric illnesses that have a substantive somatic component, the presence of occult medical conditions (eg, a brain tumor or endocrine perturbations) must be ruled out. Accordingly, a thorough physical examination is always warranted.
In addition, all patients should undergo a thorough mental status examination.
Some BDD patients who are not treated may become delusional or depressed. Moreover, in the treatment of this disorder, attempts to challenge or work with the delusion can make patients even more depressed. In patients with obsessive-compulsive disorder (OCD), the presence of BDD is associated with poor insight into obsessional beliefs and higher morbidity, reflected in a generally higher prevalence of comorbid psychiatric disorders.
People with BDD frequently develop major depressive episodes and are at risk for suicide. They also may exhibit violent behavior toward treatment providers. In a placebo-controlled study evaluating suicidality in BDD patients treated with fluoxetine, there was no significant difference between fluoxetine and placebo with regard to the emergence of suicidality; moreover, fluoxetine appeared to protect against worsening of suicidality.
In many cases, individuals with BDD experience drastic social and occupational dysfunctions that may progress to the point of social isolation. Embarrassment and fear of being scrutinized or mocked cause these individuals to avoid social situations and intimate relationships. Often victims of poor self-image, people with BDD tend to lack sufficient social skills and frequently are single or divorced.
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