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.
Epidemiology
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.
APA. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; 1994.
Allen A, Hollander E. Body dysmorphic disorder. Psychiatr Clin North Am. Sep 2000;23(3):617-28. [Medline].
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].
Cotterill JA. Body dysmorphic disorder. Dermatol Clin. Jul 1996;14(3):457-63. [Medline].
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].
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].
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].
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].
Siberry GK, Iannone R, eds. The Harriet Lane Handbook. 15th ed. St. Louis, Mo: Mosby-Year Book; 2000:615-891.
Tasman A, Jerald K, Lieberman J, eds. Body dysmorphic disorder. In: Psychiatry. Philadelphia, Pa: WB Saunders Co; 1997:1148-51.
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