eMedicine Specialties > Psychiatry > Psychosomatic

Body Dysmorphic Disorder

Author: Gary K Arthur, MD, Clinical Assistant Professor, Department of Psychiatry and Behavioral Medicine, University of South Florida College of Medicine
Coauthor(s): Kim Monnell, DO,, Neurology Consulting Staff, Department of Medicine, Bay Pines VA Medical Center
Contributor Information and Disclosures

Updated: Feb 23, 2010

Introduction

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. Body dysmorphic disorder 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 body dysmorphic disorder have comorbid conditions, such as obsessive-compulsive disorder (OCD), major depression, delusions, or social phobia. Of those with a primary diagnosis of body dysmorphic disorder, 30% meet criteria for OCD. Approximately 2-7% of patients who undergo plastic surgery have body dysmorphic disorder. Patients who undergo plastic surgery are generally 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 are expected in appearance. This often leads individuals to compare themselves to people in movies, on television, or in magazines. 

Some theories suggest 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.

Body dysmorphic disorder 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 body dysmorphic disorder is often overlooked in psychiatric settings and in medical and surgical settings. Thus, the clinician should ask specific questions about body dysmorphic disorder. For example, in a study of 110 patients with body dysmorphic disorder, 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 body dysmorphic disorder have many features in common with OCD, body dysmorphic disorder 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. Body dysmorphic disorder 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 body dysmorphic disorder 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 body dysmorphic disorder.

Some patients with body dysmorphic disorder are noted to have a delusional component to their disease. Lack of insight characterizes the delusional variant of body dysmorphic disorder.³ Patients with delusional body dysmorphic disorder are the most severely dysfunctional These patients respond well to SSRIs, not antipsychotics.

Patients with body dysmorphic disorder are more prone to major depression. Phillips et al noted that in clinical settings, 60% of patients with body dysmorphic disorder have major depression and the lifetime risk for major depression in these patients is 80%.⁴ Patients with this comorbid duo are more at risk for suicide. Determining if patients with depression also have body dysmorphic disorder is important because the treatment is more specific. Usually, major depression occurs as a result of the body dysmorphic disorder, not vice-versa. Treatment for body dysmorphic disorder is high-dose SSRIs, and patients who have major depression as a result of their body dysmorphic disorder usually do not respond to non-SSRI medications or electroconvulsive therapy.

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

Frequency

United States

Body dysmorphic disorder affects 1-2% of the general population; however, this is thought to be an underestimate because body dysmorphic disorder is frequently 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 body dysmorphic disorder 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 body dysmorphic disorder 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 body dysmorphic disorder 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 body dysmorphic disorder 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 body dysmorphic disorder is major depression. Patients with these disorders usually have major depression as a result of body dysmorphic disorder. These patients also are at increased risk for suicide; as many as 29% of patients with body dysmorphic disorder 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 body dysmorphic disorder 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

Body dysmorphic disorder 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 body dysmorphic disorder 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 body dysmorphic disorder is generally chronic. It may also occur in older adults who are overly concerned with their aging appearance.

Clinical

History

Elicit a history about body dysmorphic disorder (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 are usually ashamed to make the physician aware of how much time they spend dealing with their perceived defect. Generally, patients with body dysmorphic disorder change doctors frequently and are unhappy with the results obtained by surgical or cosmetic procedures. This disorder is frequently underdiagnosed and not properly treated. If body dysmorphic disorder 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 body dysmorphic disorder are preoccupied with more than one body part at a time.
• Asking the following questions may help determine if a patient has or is at risk for body dysmorphic disorder:
  • 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 body dysmorphic disorder or risk of body dysmorphic disorder is suspected, refer the patient to a psychiatrist for evaluation and treatment.

Physical

• Patients with body dysmorphic disorder 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 body dysmorphic disorder are not yet known. However, increasing evidence shows that genetic links may be involved.
• Preliminary results from John Hopkins University's Obsessive-Compulsive Disorder (OCD) Family Study indicate a first-degree relationship between body dysmorphic disorder and OCD.

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