by Joye C. Anestis, M.S.
Based on requests from some of our friends on Twitter (username PsychBrownBag), my topic for today is a basic description of body dysmorphic disorder (BDD). If you have requests for topics, please send them our way and we will do our best to oblige.
BDD is a common, serious, and devastating disorder, yet one about which many know very little. BDD can be found in the Somatoform Disorders section of the DSM-IV-TR. Somatoform disorders share "the presence of physical symptoms that suggest a general medical condition (hence, the term somatoform) and are not fully explained by a general medical condition, by the direct effects of a substance, or another mental disorder (e.g., Panic Disorder)" (APA, 2002, p. 485). The DSM readily admits that these illnesses were grouped together for clinical utility and not based on any shared etiology. Other Somatoform Disorders include hypochondriasis, pain disorder, conversion disorder, and somatization disorder.
There are 3 main symptoms of BDD, each of which must be present in order to warrant the diagnosis. The fundamental symptom is "Preoccupation with an imagined defect in appearance. If a slight physical anomaly is present, the person's concern is markedly excessive" (APA, 2000; p. 510). Individuals with BDD are obsessed with some flaw in the way they look and engage in a large number of behaviors to deal with, correct, or alleviate the anxiety caused by the flaw. The final 2 symptoms are part of the diagnostic criteria for every mental illness. The syndrome must cause significant distress or significant impairment before it can be considered "disordered," and the symptoms cannot be better accounted for by another mental illness.
The "defects" that trouble individuals with BDD most commonly appear on the head or face (e.g., size and shape of the nose, hair thinning, acne, wrinkles, scars, facial asymmetry or deformity) but they can involve any body part (e.g., breasts, abdomen, hands, feet, muscularity). The preoccupations are very distressing to people with BDD, and most individuals have difficulty controlling them. Significant impairment usually occurs, as self-consciousness about their "defect" may cause individuals to avoid work, school, or other public places. Folks with BDD have few friends and have difficulty with romantic relationships.
Numerous behaviors may accompany this illness. Individuals may spend many hours of the day "checking" the defect (e.g., looking in mirrors). Many engage in excessive grooming (e.g., skin picking, excessive hair removal, ritualized make-up application). Interestingly, while checking and grooming are done in hopes to reduce anxiety, they generally tend to actually increase it. Other behaviors used to control the defect or their anxiety include excessive exercise, dieting, frequent clothes changing, and excessive reassurance seeking about the defect (of course, there are many more...this is just a sampling). Most individuals with BDD have very poor insight into the excessive nature of their preoccupation. For some, the preoccupation crosses into a delusion, as they are convinced that their view of the defect is accurate and undistorted (one study found that 27-39% of BDD patients were currently delusional; Phillips, 2004). Delusions of reference are common, with individuals believing others are talking about or making fun of their "defect." Individuals with this disorder often seek medical treatment for their flaw (e.g., dermatological, dental, surgical), although surgical interventions generally tend to exacerbate symptoms (APA, 2000; Simon, 2002). Suicidality in BDD is quite high. Approximately 80% of these individuals report a history of suicidal ideation, 24-28% have attempted suicide, and 0.3% die by suicide (Phillips & Diaz, 1997; Veale et al., 1996; Phillips et al., 2005; Phillips & Menard, 2006; Harris & Barraclough, 1997).
Community prevalence estimates are not available, but estimates of clinical prevalence range from 6-40% (APA, 2000; Conroy et al., 2008). Prevalence in dermatological or cosmetic surgery settings range from 6-15% (APA, 2000; Simon, 2002). Common comborbid disorders are obsessive-compulsive disorder, social phobia, depression, delusional disorder, and eating disorders. Although estimates often conflict, BDD seems to be equally common in males and females (APA, 2000). BDD usually begins in early adolescence and is often chronic if not treated appropriately (Phillips et al., 2006).
Both cognitive-behavioral therapy and serotonin reputake inhibitors (SRI) are considered front-line treatments for BDD and both have well-documented efficacy (Phillips et al., 2008; Simon, 2002; Williams et al., 2006). SRIs, a type of antidepressant, which have been investigated include clomipramine, fluoxetine, and fluvoxamine (Simon, 2002). One RCT found superiority for clomipramine over desipramine (Hollander et al., 1999). Doses are typically those recommended for treating obsessive-compulsive disorder. Support for CBT has been documented in case studies and RCTs for group (Rosen et al., 1995) and individual (Veale et al., 1996) therapy. CBT for BDD usually involves identifying and challenging distorted thoughts about one's body, halting self-critical thoughts, exposure to anxiety-inducing situations (e.g., wearing clothing that highlights the defect), and response prevention (e.g., refraining from checking or excessive grooming). Although no study has directly compared the outcomes of individuals randomly assigned to receive either pharmacotherapy or CBT, one meta-analysis suggested that CBT may be the most effective of the two (Williams et al., 2006). Although these helpful treatments exist, it can be difficult to engage BDD patients in treatment, due to lack of insight, the presence of delusions, and the common belief that cosmetic treatments are the answer. Although I could find no clinical trial examining it, Phillips et al. (2008) suggest using motivational interviewing strategies to help engage clients in treatment. This seems like a logical suggestion (and certainly not an iatrogenic one).
In the future I will update the site with more information on this illness as I come across it. If there is more specific information you would like to know about BDD, make a note in the comment section and I will respond.
Joye Anestis is a doctoral candidate in clinical psychology at Florida State University.
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