eMedicine Specialties > Pediatrics: Developmental and Behavioral > Medical Topics

Somatoform Disorder: Body Dysmorphic

Author: Sing-Yi Feng, MD, Assistant Professor, Department of Pediatrics, Division of Emergency Medicine, Section of Medical Toxicology, University of Texas Southwestern Medical Center; Staff Toxicologist, North Texas Poison Center, Parkland Memorial Hospital
Coauthor(s): Jagvir Singh, MD, Director, Division of Pediatric Emergency Medicine, Lutheran General Hospital of Park Ridge
Contributor Information and Disclosures

Updated: Mar 17, 2008

Introduction

Background

Body dysmorphic disorder (BDD) is a type of somatoform disorder characterized by a patient's persistent and unremitting preoccupation with an imagined defect in appearance (eg, a large nose) or an exaggerated sense of the severity of a perceived physical flaw. According to the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV), this excessive preoccupation results in notable emotional distress and impairment in function at school, work, or home or during other important life functions.1

Patients with BDD seek actions, such as cosmetic surgery, to correct their perceived malformation. Patients with symptoms exclusively focused on a preoccupation with body weight and shape or perceived inappropriateness of sexual characteristics are not diagnosed with BDD and frequently meet criteria for other disorders such as anorexia nervosa or gender identity disorder.

Parents of children with BDD may seek psychiatric evaluation after witnessing excessive mirror checking, time-consuming grooming, and an inability to be reassured about the perceived flaw. From a developmental perspective, some preoccupation with appearance is common during adolescence; however, adolescents with BDD exhibit clinically significant distress or impairment in functioning. People with BDD are often involved in costly and potentially dangerous cosmetic surgeries and dermatological treatments, often in futile efforts to correct their perceived intolerable physical flaws.

Pathophysiology

The pathophysiology of BDD is still unknown, although numerous theories have been suggested.2 The neurobiology of BDD is only now under investigation. Evidence from demographic features, phenomenology, course, and treatment response suggest BDD may be related to obsessive-compulsive disorder (OCD), and the pathophysiology may involve serotonin.3

Sociologically speaking, BDD has been explained as an excessive interpretation of society's ideals of physical beauty and an overvaluing of available cosmetic procedures to correct perceived flaws. Patients with BDD are often insecure, sensitive, obsessional, schizoid, anxious, narcissistic, and introverted and have hypochondriac traits. Because BDD has a strong association with hypochondriasis and other conditions that involve obsessional thoughts, using a neurobiologic approach, BDD is believed to preferentially respond to selective serotonin reuptake inhibitors (SSRIs). Some evidence indicates that BDD and other OCDs may be aggravated by m -chlorophenylpiperazine, a partial serotonin agonist.

Frequency

United States

An estimated 1% of the population is affected by BDD.4 No epidemiologic data are currently available for BDD in children and adolescents.

International

In cosmetic surgery and dermatology settings, 6-15% of patients are estimated to have BDD. No epidemiologic data are currently available for BDD in children and adolescents.

Patients who undergo cosmetic surgery do not seem to have increased incidence of generalized body dissatisfaction; however, when surveyed about specific body parts, they have a much higher incidence of specific body part dissatisfaction.5

Mortality/Morbidity

Phillips et al (1995) have reported a virtual absence of psychiatric literature on BDD in children and adolescents despite preliminary evidence suggesting that the onset of BDD occurs in adolescence.3  They studied functional impairment in 130 patients with BDD. The findings were as follows:

  • Social dysfunction: Thirty-two percent of patients had been housebound at least for a week because of their symptoms. Ninety-eight percent of individuals in the group had significant impairment in social functioning. Seventy-four percent of patients had impairments in academic or occupational functioning. Thirteen percent of affected individuals had received government disability payments because of BDD.
  • Suicide risk: A distinct risk of suicide is observed, especially in women. Twenty-nine percent of the BDD group studied made at least one suicide attempt. Sixty percent of these attempts were due to BDD symptoms.

Race

No racial predilection is known.

Sex

The sex distribution of BDD is not known. In males, the preoccupation is often related to obsessions about genitalia. Women with BDD are often preoccupied with their hair, face, and breasts.

Age

BDD generally starts during adolescence and is usually continuous over time, with waxing and waning symptoms. For many patients, it becomes chronic. The body part that is the focus of concern may remain the same or may change over time.

Clinical

History

  • Natural history
    • Body dysmorphic disorder (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.
  • Behavior
    • BDD may lead to time-consuming unproductive rumination. Patients adopt repetitive, obsessive, and ritualistic behavior and may spend most of their time in front of a mirror, repeatedly checking their perceived imperfections.
    • 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 avoid job interviews, dating, and peers.
    • Patients also have a constant need for reassurance about their perceived flaws and can often be extremely demanding to primary care physicians and cosmetic surgeons in their pursuit of perfection.
  • Common areas of perceived imperfections
    • Skin
    • Face
    • Nose
    • Mouth
    • Hair
    • Eyelids
    • Wrinkles
    • Excessive greasiness
    • Acne
    • Excessive facial hair
    • Nasal size and shape
    • Teeth
    • Bite of jaw
    • Breasts
    • Genitals
    • Buttocks
    • Lips

Physical

Patients with BDD often have no distinguishing physical or dermatologic findings.

Causes

Causes are unknown at this time.

More on Somatoform Disorder: Body Dysmorphic

Overview: Somatoform Disorder: Body Dysmorphic
Differential Diagnoses & Workup: Somatoform Disorder: Body Dysmorphic
Treatment & Medication: Somatoform Disorder: Body Dysmorphic
Follow-up: Somatoform Disorder: Body Dysmorphic
References
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References

  1. APA. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; 1994.

  2. Allen A, Hollander E. Body dysmorphic disorder. Psychiatr Clin North Am. Sep 2000;23(3):617-28. [Medline].

  3. Phillips KA, Atala KD, Albertini RS. Case study: body dysmorphic disorder in adolescents. J Am Acad Child Adolesc Psychiatry. Sep 1995;34(9):1216-20. [Medline].

  4. Cotterill JA. Body dysmorphic disorder. Dermatol Clin. Jul 1996;14(3):457-63. [Medline].

  5. Sarwer DB, Wadden TA, Pertschuk MJ, Whitaker LA. Body image dissatisfaction and body dysmorphic disorder in 100 cosmetic surgery patients. Plast Reconstr Surg. May 1998;101(6):1644-9. [Medline].

  6. Neziroglu F, Hsia C, Yaryura-Tobias JA. Behavioral, cognitive, and family therapy for obsessive-compulsive and related disorders. Psychiatr Clin North Am. Sep 2000;23(3):657-70. [Medline].

  7. Simon GE, Savarino J, Operskalski B, Wang PS. Suicide risk during antidepressant treatment. Am J Psychiatry. Jan 2006;163(1):41-7. [Medline]. [Full Text].

  8. Fritz GK, Fritsch S, Hagino O. Somatoform disorders in children and adolescents: a review of the past 10 years. J Am Acad Child Adolesc Psychiatry. Oct 1997;36(10):1329-38. [Medline].

  9. Siberry GK, Iannone R, eds. The Harriet Lane Handbook. 15th ed. St. Louis, Mo: Mosby-Year Book; 2000:615-891.

  10. Tasman A, Jerald K, Lieberman J, eds. Body dysmorphic disorder. In: Psychiatry. Philadelphia, Pa: WB Saunders Co; 1997:1148-51.

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Further Reading

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Keywords

body dysmorphic disorder, BDD, dysmorphophobia, dermatologic hypochondriasis, beauty hypochondriasis, dermatological nondisease, primary monosymptomatic hypochondriacal psychosis, perceived physical flaw, perceived malformation, imagined appearance defect, somatoform disorder, cosmetic surgery, obsessive-compulsive disorder, OCD

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Contributor Information and Disclosures

Author

Sing-Yi Feng, MD, Assistant Professor, Department of Pediatrics, Division of Emergency Medicine, Section of Medical Toxicology, University of Texas Southwestern Medical Center; Staff Toxicologist, North Texas Poison Center, Parkland Memorial Hospital
Sing-Yi Feng, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Emergency Physicians, and American College of Medical Toxicology
Disclosure: Nothing to disclose.

Coauthor(s)

Jagvir Singh, MD, Director, Division of Pediatric Emergency Medicine, Lutheran General Hospital of Park Ridge
Jagvir Singh, MD is a member of the following medical societies: American Academy of Pediatrics
Disclosure: Nothing to disclose.

Medical Editor

Carol Diane Berkowitz, MD, Executive Vice Chair, Department of Pediatrics, Professor, Harbor-University of California at Los Angeles Medical Center
Carol Diane Berkowitz, MD is a member of the following medical societies: Alpha Omega Alpha, Ambulatory Pediatric Association, American Academy of Pediatrics, American College of Emergency Physicians, American Medical Association, American Pediatric Society, and North American Society for Pediatric and Adolescent Gynecology
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine.com, Inc
Disclosure: Pfizer Inc Stock Investment from broker recommendation; Avanir Pharma Stock Investment from broker recommendation

CME Editor

Carrie Sylvester, MD, MPH, Director of Education in Child and Adolescent Psychiatry, Professor, Departments of Psychiatry and Pediatrics, Northwestern University Medical School
Carrie Sylvester, MD, MPH is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, American Academy of Pediatrics, American Medical Women's Association, American Psychiatric Association, and American Society for Adolescent Psychiatry
Disclosure: Nothing to disclose.

Chief Editor

Caroly Pataki, MD, Professor of Clinical Psychiatry, Department of Psychiatry and Biobehavioral Sciences, Division Chair of Child and Adolescent Psychiatry, Director of Training, Child and Adolescent Psychiatry Residency Program, University of Southern California Keck School of Medicine
Caroly Pataki, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, New York Academy of Sciences, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

 
 
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