Body dysmorphic disorder

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:  Chelsea Mae Nobleza, M.D.[2] Alonso Alvarado, M.D. [3]

Synonyms and keywords: BDD

## Overview[edit | edit source]

Body dysmorphic disorder (BDD) is a mental disorder that involves a disturbed body image where there is an excessive preoccupation with the physical appearance despite the fact there may be no noticeable disfigurement or defect. Common areas of concern in most people suffering from BDD include perceived flaws relating to the face, nose, eyes, skin, and hair. BDD combines obsessive and compulsive aspects, which links it to the OCD spectrum disorders. People with BDD may engage in compulsive mirror checking behaviors or mirror avoidance, typically think about their appearance for more than one hour a day, and in severe cases may drop all social contact and responsibilities as they become homebound. The disorder is linked to an unusually high suicide rate among all mental disorders.

## Historical Perspective[edit | edit source]

BDD was first documented in 1886 by the researcher Morselli, who called the condition simply "Dysmorphophobia". BDD was first recorded/formally recognized in 1997 as a disorder in the DSM; however, in 1987 it was first truly recognized by the American Psychiatric Association.

In his practice, Freud eventually had a patient who would today be diagnosed with the disorder; Russian aristocrat Sergei Pankejeff, nicknamed "The Wolf Man" by Freud himself in order to protect Pankejeff's identity, had a preoccupation with his nose to an extent that greatly limited his functioning.

## Causes[edit | edit source]

The exact etiology of BDD is unclear, but it is likely an interplay in social, psychological, and biological factors. [1]

### Social Factors[edit | edit source]

Individuals with BDD have suffered from some form of abuse in the past. These experiences comprised emotional neglect in 68%, emotional abuse in 56 %, physical abuse in 34.7%, and sexual abuse in 28% of patients. [1] [2]

### Neurobiological Model for BDD[edit | edit source]

#### Detailed processing and visual processing streams[edit | edit source]

A dysfunction in visual processing systems accounts for the heightened detail processing in BDD patients. This is due to the observed early travel of first-order visual information from V1 and V2 areas to temporal regions in the left hemisphere, where detail and structure are encoded. In addition, there is the faulty formation of holistic elements of visual information due to decreased use of the processing of second-order visual information, as evidenced by decreased activity in the lateral occipital cortex and precuneus. These findings explain the enhanced awareness of perceived imperfections in BDD patients.[3] [4] [5] [6] [7]

#### Frontostriatal systems[edit | edit source]

Increased activity and reduced grey matter volumes in the frontostriatal and subcortical regions are linked to BDD patients' repetitive and compulsive behaviors, which is similarly observed in OCD patients.This is supported by abnormal circuitry seen in the inferior occipitofrontal fasciculus, a pathway that connects the frontal and occipital lobes via the caudate. The caudate nucleus seems to play an essential role in inappropriately mediating motor inhibition. [8] [9]

#### Temporolimbic systems[edit | edit source]

The limbic system is also involved in BDD. In particular, the right amygdala demonstrates hyperactivity during visual tasks and mediates the relationship between anxiety and ventral visual system activation. This results in heightened emotions to visual information.[10] [11]

### Genetic Factors[edit | edit source]

A genetic component may also be involved in BBD. Patients with BDD have a family member with a similar condition in 8% of patients, while 7% of BDD patients have first-degree family members with OCD. [12]

## Differential Diagnosis[edit | edit source]

Body dysmorphic disorder must be differentiated from: [13]

* Anxiety disorder

* Eating disorders

* Illness anxiety disorder

* Major depressive disorder
* Other obsessive-compulsive disorders

* Psychotic disorders

## Epidemiology and Demographics[edit | edit source]

### Prevalence[edit | edit source]

The prevalence of BDD is at 0.7-2.4% in the general population making it more common than other psychiatric disorders such as anorexia nervosa or schizophrenia. In clinical settings, BDD seems to have a prevalence of 9-13% in dermatology settings, 3-53% in cosmetic surgery settings and it coexists with OCD in 8-37% of patients. Considering how common this condition is, many individuals don’t report their symptoms due to embarrassment. [14]

### Gender[edit | edit source]

BDD affects more women than men (2.5% vs 2.2%) and the average onset is at 17 years old.[15]

## Risk Factors[edit | edit source]

Some of risk factors include: [13]

* First-degree relatives of patients with obsessive compulsive disorder (OCD)
* History of childhood abuse

## Natural History, Complications, and Prognosis[edit | edit source]

### Natural History[edit | edit source]

BDD usually develops in adolescence, a time when people are generally most sensitive about their appearance. However, many patients suffer for years before seeking help. When they do seek help through mental health professionals, patients often complain of other symptoms such as depression, social anxiety or obsessive-compulsive disorder, but do not reveal their real concern over body image. Most patients cannot be convinced that they have a distorted view of their body image, due to the very limited knowledge of the disorder as compared to OCD or others. Male patients have more risk of developing the obsession around the genitalia and females have higher risk of developing eating disorders associated with the BDD.[16]

### Complications[edit | edit source]

#### Suicide Risk[edit | edit source]

* The suicide rates in patients with BDD are high at all ages, with a higher incidence in adolescent patients.
* Risk factors associated with completed suicide in patients with BDD are suicide thoughts and previous attempts, association with major depressive syndrome and demographic locations associated with high rates of suicide.
* Phillips & Menard (2006) found the completed suicide rate in patients with BDD to be 45 times higher than in the general US population. This rate is more than double that of those with Clinical depression and three times as high as those with bipolar disorder. There has also been a suggested link between undiagnosed BDD and a higher than average suicide rate among people who have undergone cosmetic surgery[17][18].

#### Functional Consequences of BDD[edit | edit source]

* Impaired psychosocial development which can range from mild (the patient avoids social situations) to severe (the patient doesn't leave the house).
* The severity of the disorder is usually directly associated with the degree of psychosocial impairment.
* Chronically low self-esteem is characteristic of those with BDD due to the value of oneself being so closely linked with their perceived appearance. BDD causes chronic social anxiety for those suffering from the disorder[4]

### Prognosis[edit | edit source]

Many individuals with BDD have repeatedly sought treatment from dermatologists or cosmetic surgeons with little satisfaction before finally accepting psychiatric or psychological help. Treatment can improve the outcome of the illness for most people. Other patients may function reasonably well for a time and then relapse, while others may remain chronically ill. Research on outcomes without therapy is not known but it is thought the symptoms persist unless treated. [19]

## Diagnosis[edit | edit source]

### Diagnostic Criteria[edit | edit source]

#### DSM-V Diagnostic Criteria for Body Dysmorphic Disorder Body Dysmorphic Disorder[edit | edit source]

“  |

* The patient is preoccupied with an imagined defect of appearance or is excessively concerned about a slight physical anomaly.

AND

* During the course of the disease the patient develops behaviors such as excessive mirror checking, grooming, seek for reassurance or compare his/her appearance with others.

AND

* This preoccupation causes clinically important distress or impairs work, social or personal functioning.

AND

* Another mental disorder (such as Anorexia Nervosa) does not better explain the preoccupation.

| ”

|
|

* One must also specify if a patient with BDD has muscle dysmorphia where one seems to be preoccupied in a too small or insufficiently muscular physique even though they have a normal-looking build.

* In addition, the degree of insight must also be evaluated [13].

### Symptoms[edit | edit source]

Symptoms of body dysmorphic disorder include:[13]

* Compulsive mirror checking, glancing in reflective doors, windows, and other reflective surfaces
* Alternatively, an inability to look at one's own reflection or photographs of oneself; often the removal of mirrors from the home
* Compulsive skin-touching, especially to measure or feel the perceived defect
* Reassurance-seeking from loved ones
* Social withdrawal and co-morbid depression.
* Obsessive viewing of favorite celebrities or models the person suffering from BDD may wish to resemble
* Excessive grooming behaviors: combing hair, plucking eyebrows, shaving, etc
* Obsession with plastic surgery or multiple plastic surgeries with few satisfactory results for the patient
* In obscure cases patients have performed plastic surgery on themselves, including liposuction and various implants with disastrous results

### Common Locations of imagined Defects[edit | edit source]

In research carried out by Dr. Katharine Philips, involving over 500 patients, the percentage of patients concerned with the most common locations were as follows:

* Skin (73%)
* Hair (56%)
* Nose (37%)
* Weight (22%)
* Stomach (22%)
* Breasts/ Chest/ Nipples (21%)
* Eyes (20%)
* Thighs (20%)
* Teeth (20%)
* Legs (Overall) (18%)
* Body Build/ Bone Structure (16%)
* Ugly Face (General) (14%)
* Lips (12%)
* Buttocks (12%)
* Chin (11%)
* Fingers
* Eyebrows (11%)

People with BDD often have more than one area of concern. Source:  The Broken Mirror, Katharine A Philips, Oxford University Press, 2005 ed, p56

## Treatment[edit | edit source]

* The combination of Cognitive Behavioral Therapy (CBT) and Selective Serotonin Reuptake Inhibitors (SSRIs) are the mainstay treatments for BDD.

* CBT involves psychotherapy centered on developing coping mechanisms by altering repetitive behavior patterns and thoughts. Strategies involve gradual sensitization of fear-inducing circumstances and retraining of thoughts. They are administered for 12-22 weeks of weekly sessions.[20] [21]

* SSRIs, more commonly fluoxetine and escitalopram, are used to treat BDD and its accompanying comorbidities such as major depressive disorder, (social anxiety disorder, and OCD. The incorporation of clomipramine is also initiated in some cases where SSRIs may not be of benefit. What should be noted with the use of SSRIs in the treatment of BDD is that they require higher doses compared to doses used to treat other psychiatric conditions. Typically, observed response to SSRI requires 12-16 weeks to determine response.[22]

## References[edit | edit source]

1. ↑ 1.0 1.1 Buhlmann, Ulrike; Marques, Luana M.; Wilhelm, Sabine (2012). "Traumatic Experiences in Individuals With Body Dysmorphic Disorder". Journal of Nervous & Mental Disease. 200 (1): 95–98. doi:10.1097/NMD.0b013e31823f6775. ISSN 0022-3018.
2. ↑ Didie, Elizabeth R.; Tortolani, Christina C.; Pope, Courtney G.; Menard, William; Fay, Christina; Phillips, Katharine A. (2006). "Childhood abuse and neglect in body dysmorphic disorder". Child Abuse & Neglect. 30 (10): 1105–1115. doi:10.1016/j.chiabu.2006.03.007. ISSN 0145-2134.
3. ↑ Arienzo, Donatello; Leow, Alex; Brown, Jesse A; Zhan, Liang; GadElkarim, Johnson; Hovav, Sarit; Feusner, Jamie D (2013). "Abnormal Brain Network Organization in Body Dysmorphic Disorder". Neuropsychopharmacology. 38 (6): 1130–1139. doi:10.1038/npp.2013.18. ISSN 0893-133X.
4. ↑ Feusner, Jamie D.; Arienzo, Donatello; Li, Wei; Zhan, Liang; GadElkarim, Johnson; Thompson, Paul M.; Leow, Alex D. (2013). "White matter microstructure in body dysmorphic disorder and its clinicalcorrelates". Psychiatry Research: Neuroimaging. 211 (2): 132–140. doi:10.1016/j.pscychresns.2012.11.001. ISSN 0925-4927.
5. ↑ Leow, Alex D.; Zhan, Liang; Arienzo, Donatello; GadElkarim, Johnson J.; Zhang, Aifeng F.; Ajilore, Olusola; Kumar, Anand; Thompson, Paul M.; Feusner, Jamie D. (2012). "Hierarchical Structural Mapping for Globally Optimized Estimation of Functional Networks". 7511: 228–236. doi:10.1007/978-3-642-33418-4_29. ISSN 0302-9743.
6. ↑ Li, Wei; Arienzo, Donatello; Feusner, Jamie D. (2013). "Body Dysmorphic Disorder: Neurobiological Features and an Updated Model". Zeitschrift für Klinische Psychologie und Psychotherapie. 42 (3): 184–191. doi:10.1026/1616-3443/a000213. ISSN 1616-3443.
7. ↑ Grace, Sally A.; Labuschagne, Izelle; Kaplan, Ryan A.; Rossell, Susan L. (2017). "The neurobiology of body dysmorphic disorder: A systematic review and theoretical model". Neuroscience & Biobehavioral Reviews. 83: 83–96. doi:10.1016/j.neubiorev.2017.10.003. ISSN 0149-7634.
8. ↑ Saxena, Sanjaya; Rauch, Scott L. (2000). "FUNCTIONAL NEUROIMAGING AND THE NEUROANATOMY OF OBSESSIVE-COMPULSIVE DISORDER". Psychiatric Clinics of North America. 23 (3): 563–586. doi:10.1016/S0193-953X(05)70181-7. ISSN 0193-953X.
9. ↑ Buchanan, B. G.; Rossell, S. L.; Maller, J. J.; Toh, W. L.; Brennan, S.; Castle, D. J. (2013). "Brain connectivity in body dysmorphic disorder compared with controls: a diffusion tensor imaging study". Psychological Medicine. 43 (12): 2513–2521. doi:10.1017/S0033291713000421. ISSN 0033-2917.
10. ↑ Buhlmann, Ulrike; Winter, Anna; Kathmann, Norbert (2013). "Emotion recognition in body dysmorphic disorder: Application of the Reading the Mind in the Eyes Task". Body Image. 10 (2): 247–250. doi:10.1016/j.bodyim.2012.12.001. ISSN 1740-1445.
11. ↑ Monzani, Benedetta; Rijsdijk, Fruhling; Iervolino, Alessandra C.; Anson, Martin; Cherkas, Lynn; Mataix-Cols, David (2012). "Evidence for a genetic overlap between body dysmorphic concerns and obsessive-compulsive symptoms in an adult female community twin sample". American Journal of Medical Genetics Part B: Neuropsychiatric Genetics. 159B (4): 376–382. doi:10.1002/ajmg.b.32040. ISSN 1552-4841.
12. ↑ Bjornsson, Andri S.; Didie, Elizabeth R.; Grant, Jon E.; Menard, William; Stalker, Emily; Phillips, Katharine A. (2013). "Age at onset and clinical correlates in body dysmorphic disorder". Comprehensive Psychiatry. 54 (7): 893–903. doi:10.1016/j.comppsych.2013.03.019. ISSN 0010-440X.
13. ↑ 13.0 13.1 13.2 13.3 Diagnostic and statistical manual of mental disorders : DSM-5. Washington, D.C: American Psychiatric Association. 2013. ISBN 0890425558.
14. ↑ Bjornsson AS, Didie ER, Phillips KA (2010). "Body dysmorphic disorder". Dialogues Clin Neurosci. 12 (2): 221–32. PMC 3181960. PMID 20623926.CS1 maint: Multiple names: authors list (link)
15. ↑ Hong, Kevin; Nezgovorova, Vera; Uzunova, Genoveva; Schlussel, Danya; Hollander, Eric (2019). "Pharmacological Treatment of Body Dysmorphic Disorder". Current Neuropharmacology. 17 (8): 697–702. doi:10.2174/1570159X16666180426153940. ISSN 1570-159X.
16. ↑ Phillips KA (2006). "The Presentation of Body Dysmorphic Disorder in Medical Settings". Prim psychiatry. 13 (7): 51–59. PMC 1712667. PMID 17183412.
17. ↑ http://ajp.psychiatryonline.org/cgi/content/full/163/7/1280
18. ↑ http://www.newscientist.com/channel/health/mg19225745.200-cosmetic-surgery-special-when-looks-can-kill.html
19. ↑ Higgins S, Wysong A (2018). "Cosmetic Surgery and Body Dysmorphic Disorder - An Update". Int J Womens Dermatol. 4 (1): 43–48. doi:10.1016/j.ijwd.2017.09.007. PMC 5986110. PMID 29872676.
20. ↑ Hofmann, Stefan G.; Asmundson, Gordon J.G.; Beck, Aaron T. (2013). "The Science of Cognitive Therapy". Behavior Therapy. 44 (2): 199–212. doi:10.1016/j.beth.2009.01.007. ISSN 0005-7894.
21. ↑ Wilhelm, Sabine; Phillips, Katharine A.; Didie, Elizabeth; Buhlmann, Ulrike; Greenberg, Jennifer L.; Fama, Jeanne M.; Keshaviah, Aparna; Steketee, Gail (2014). "Modular Cognitive-Behavioral Therapy for Body Dysmorphic Disorder: A Randomized Controlled Trial". Behavior Therapy. 45 (3): 314–327. doi:10.1016/j.beth.2013.12.007. ISSN 0005-7894.
22. ↑ Hong K, Nezgovorova V, Uzunova G, Schlussel D, Hollander E (2019). "Pharmacological Treatment of Body Dysmorphic Disorder". Curr Neuropharmacol. 17 (8): 697–702. doi:10.2174/1570159X16666180426153940. PMC 7059151 Check `|pmc=` value (help). PMID 29701157.CS1 maint: Multiple names: authors list (link)