Psychiatric Manifestations of Body Dysmorphic Disorder 

Body dysmorphic disorder (BDD) is a relatively common and often severe psychiatric illness that is likely underrecognized and underreported. It is classified as a somatoform disorder in DSM-IV-TR; however, some authors have argued that it may be considered as part of the obsessive-compulsive or psychotic disorder spectrum.^[1] The essential feature of this disorder is a preoccupation with an imagined defect in appearance or disproportionate concern with a slight physical anomaly. These preoccupations most often involve the nose, ears, face, hair, or features related to sexuality (such as breasts in women or muscular build or penis size in men), yet any body part may occupy the patient’s focus. By definition, body dysmorphic disorder causes significant distress or impairment in social, occupational, or other areas of functioning.^[2]

Data suggest that quality of life and psychosocial functioning is as poor as, or poorer than, in those with obsessive-compulsive disorder (OCD).^[3] BDD is associated with high rates of hospitalization (48%), and high rates of suicidal ideation and attempts.^{[4, 5]} A history of suicidal ideation attributed primarily to BDD is reported in 45-70% of those with BDD, and past suicide attempts are reported in 22-24%.^[6]

BDD affects 1-2% of the general population, making it more common than schizophrenia and bipolar disorder, and its prevalence has been reported to be as high as 7-15% in those undergoing cosmetic surgery.^{[7, 8, 9, 10]} Persons with BDD who choose to undergo plastic surgery are generally unhappy with the results, and later often become concerned with another body part. They are often consumed with thoughts about the postoperative site. Surgeons and dermatologists have occasionally been victims of violence, even murder, by patients with BDD who are in despair over their procedural outcomes.^[11]

The researcher Morselli first documented body dysmorphic disorder in 1886. Freud famously treated a patient who would likely today be diagnosed with body dysmorphic disorder. Freud nicknamed this patient "Wolf Man" in his writings to protect the identity of Sergei Pankejeff, the Russian aristocrat he was treating, who was so preoccupied with his nose that it significantly impaired his functioning.

Body dysmorphic disorder was originally called dysmorphophobia and was first included parenthetically as an example of an atypical somatoform disorder in the DSM-III. It was not until the release of DSM-III-R in 1987, that it was renamed body dysmorphic disorder. The DSM-IV-TR currently classifies it under the somatoform disorders. However, the DSM-V work group has recommended that BDD be reclassified from somatoform disorders to anxiety and obsessive-compulsive spectrum disorders, likely reflecting its similarities in both pathophysiology and treatment to OCD.

Per DSM-IV-TR criteria, body dysmorphic disorder is defined as the following:

A. Preoccupation with an imagined defect in appearance. If a 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 (eg, dissatisfaction with body shape and size in anorexia nervosa).

BDD usually appears during early adolescence, and, when left untreated, is often a chronic condition. Social values and mass media greatly influence body image, and, in turn, self-image. Most people have concerns related to appearance; however, this concern is considered pathologic when it causes distress that interferes with social or occupational functioning.

Case study

Ms. X, a 33-year-old single white female, presents with preoccupation focused on her "sparse" hair and "hideous" nose. She began worrying excessively about her appearance in her middle school years, focusing at that time on her acne and "extremely wide" forehead. She found her preoccupations very distressing but was too embarrassed to reveal this to family or friends. Although friends found her appearance normal, she was utterly convinced there was a problem. She generally spent 4-5 hours per day thinking about her perceived defect, carefully comparing her face to others, compulsively grooming herself, and checking herself in a mirror repetitively.

Due to her preoccupation she missed 1-2 days of work per week, and it prevented her from going out with friends or going on a date. She felt so distressed by her problem that she contemplated suicide. She then had 2 rhinoplasties done by a plastic surgeon to her specifications to fix her perceived nasal defect. However, she felt that her nose looked no better and she continued to be distressed by her appearance. She was seeking psychiatric help for her depression, which she related to her perceived defects.

Although our understanding of the pathophysiology of body dysmorphic disorder is limited, it remains a subject of continuing research. A more robust understanding of BDD’s pathophysiology will surely inform and improve available treatment options. Recent studies highlight a variety of plausible etiological mechanisms, including such hypotheses as abnormal visual processing and hypo-NMDAR signal transduction.^{[12, 13]}

Based on its pattern of heritability, genetic factors are suspected to play a causal role in the development of BDD. Family members of a patient diagnosed with BDD show a prevalence rate of BDD that is 4-8 times that found in the general population. There is also a heritable association of BDD in patients with OCD. Unfortunately, to date there is a dearth of studies that could more fully illuminate the molecular genetic etiology of BDD.^[14]

In 2000, Deckersbach et al found that patients with body dysmorphic disorder had impaired verbal and nonverbal memory encoding strategies.^[15] This finding suggests an involvement of executive memory deficits with a lesion of the frontostriatal connections. A similar abnormality in memory encoding also occurs in patients with OCD. Additionally, enlarged white matter volume and asymmetry of the caudate nucleus, favoring the left side, have been observed in patients with body dysmorphic disorder.

A study published in 2007 by Dr. Jamie Feusner has suggested that in body dysmorphic disorder, fundamental differences occur in the visual processing of faces. Katharine Phillips, MD, a professor of psychiatry at Brown University and prominent BDD researcher, has stated, "Dr. Feusner's study is groundbreaking."^[15] The study also found that subjects with BDD had greater left hemisphere activation and may possess a cognitive style that relies more heavily on extraction and processing of details. Feusner and colleagues explain the implications of these functional neuroimaging findings:

“BDD patients may process faces in a piecemeal manner, while healthy controls’ perception of faces may be more configural and holistic. These laterality patterns in the BDD participants suggest a bias for local, or detail oriented, processing of faces over global processing.”^[14]

Several studies have explored the causal role for disruptions in serotonergic transmission. Many of these are based on evidence that illustrates the effectiveness of SSRIs in the treatment of BDD. Overall, the exact role for serotonergic transmission in the etiology of BDD remains the subject of continuing research.^[14]

In addition to the neuroanatomical, neurochemical, and genetic models of causality in BDD, several cognitive-behavioral models have been developed to explain BDD. While it is recognized that most people find at least 1 aspect of their appearance in which they are unsatisfied, people with BDD obsess on these perceived defects. These individuals are believed to use maladaptive cognitive processes that overemphasize the importance of perceived attractiveness. Following this logic, individuals with BDD, placing a disproportionate emphasis on physical attractiveness, view themselves negatively, experiencing low self-esteem, anxiety, shame, and sadness. These individuals use maladaptive coping methods such as mirror-gazing or avoidance.^[16]

Frequency

United States

Body dysmorphic disorder affects 1-2% of the general population. Since it is underdiagnosed, this may be an underestimate. Patients underreport to their physicians because of intense shame. Prevalence in patients undergoing plastic or cosmetic surgery ranges from 7-15%.^[10]

International

Incidence and prevalence are unknown with any precision or accuracy.

Mortality/Morbidity

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.

Major depression is a common comorbidity; 60% of patients with BDD have major depression. Patients with BDD often have major depression as a result of body dysmorphic disorder. These patients also are at increased risk for suicide. Suicidal ideation attributed primarily to BDD is reported in 45-70% of those with BDD, and past suicide attempts are reported in 22-24%.^[6] The annual rate of completed suicide (preliminary data based on 1 pilot study) in BDD is alarmingly high, at 0.3%.^[6]

Because of frequent comorbidity with other conditions, the diagnosis of body dysmorphic disorder is often overlooked. In a study of 110 patients with body dysmorphic disorder, 51% did not reveal their symptoms to their therapist.

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 and activities centered on concealing or confirming the perceived deformity that consume most of the patient's time. Compared with OCD, body dysmorphic disorder has much higher rates of poor insight, ideas of reference, overvalued ideas, and delusions.

Social phobia is another common comorbid disorder found in those with body dysmorphic 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 near equal frequency. Female to male ratios are in the range of 1:1 to 3:2.^[17]

Women more often have comorbid anxiety and panic disorder and are obsessed with legs and breasts.

Men are more likely to become preoccupied with the muscle size, described as "muscle dysmorphia" and considered as a subcategory of body dysmorphic disorder.^[18] The disorder affects mostly men, particularly those who engage in weight lifting or body building. Men are also more likely to have a diagnosis of substance abuse (50%) and be single.

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.^[19] 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.