Body dysmorphic disorder: through a glass darkly

Is body dysmorphic disorder a real disease or simply vanity? Simon Clausen takes a second look

Most people care about how they look, and 93% of women and 82% of men care about their appearance and try to improve it.1 Many people wish that they were taller, their skin smoother, or stomach flatter. Some people buy flattering clothes or wear make-up. But when do normal concerns become an obsession?

Body dysmorphic disorder (BDD) was previously known as dysmorphophobia. The term “dysmorphic” comes from the Greek for “ugliness of face.” The primary distinguishing feature of BDD is not only a dislike of a perceived defect in your physical appearance but an obsessive preoccupation with it. BDD is a potentially debilitating psychiatric illness and goes beyond normal concern with one’s appearance, often considerably impairing social and occupational functioning. The disorder has been described around the world for more than a century. One of psychiatry’s most famous patients, the Wolf Man, may have had BDD. Sigmund Freund, the Wolf Man’s first psychoanalyst did not mention symptoms of BDD in his description of the patient. In 1928, the Wolf Man’s second psychoanalyst, Ruth Brunswick, wrote about her patient’s preoccupation. She noted that he “neglected his daily life and work because he was engrossed, to the exclusion of all else, in the state of his nose... his life was centered on the little mirror in his pocket.”1

How widespread is it?

BDD can go unrecognised as individuals’ are often too ashamed to discuss their symptoms, often because of secrecy and shame. Several studies have shown incidence is higher than first thought. One study found that the condition may affect up to 1% of the population in the United States2 and another showed that 4% of US college students seemed to have BDD.3 the condition affects as many men as women,4 and the age of onset is commonly 20-30 years.

Clinical features

Obsessions related to BDD may manifest as excessive disproportionate concerns about a minor physical anomaly or as recurrent thoughts provoking anxiety about an entirely imagined defect. It is extremely difficult, if not impossible, to see things the way the patient does.

The most common imagined defects are of the face, including moles or freckles, acne, the shape of the nose, excessive facial hair, and facial asymmetries. More rarely the complaint involves the feet, hands, breasts, genitals, and muscles. Studies have shown that different sexes tend to obsess over different areas of the body (box 1). Men were also more likely to be unmarried and although men were as likely as women to seek non-psychiatric medical and surgical treatment, women were more likely to receive such care.4

Most people with BDD engage in compulsive behaviours (box 2). Patients may spend many hours in front of a mirror. Four fifths of patients with BDD report excessive mirror checking. This may be because patients with BDD are driven by the hope that they will look different, the desire to know exactly how they look, or a belief that they will feel worse if they resist gazing. But people with BDD often feel worse after mirror gazing. Depression and suicidal thoughts are not uncommon.

One patient with BDD believes her skin is uneven and her jaw too large. “I wish I could convince my parents to take me to a plastic surgeon,” said the 15 year old girl. She has begun to use heavy make-up to cover her skin and asks her parents how she looks about 10 times a day.

Comorbidity with other psychiatric disorders

A relationship between BDD and other psychiatric disorders has been highlighted. The links appear to be greatest with anorexia nervosa (box 3) and obsessive compulsive disorder (OCD; box 4). BDD may be a non-specific symptom of such conditions.

In some patients, the symptoms of BDD and anorexia nervosa closely overlap, making it difficult to set them apart. BDD is relatively common in patients with anorexia nervosa and the presence of comorbid BDD may indicate a more severe form of the illness.5

LAURENT REBOURS/AP

In 1903, Pierre Janet classified BDD symptoms within a class of syndromes similar to OCD, referring to BDD as obsession with shame of the body.

The following quote from a patient highlights a distinct difference between the two conditions. “My OCD rituals gave me some relief—each check temporarily relieved my anxiety. The BDD rituals didn’t relieve my anxiety even temporarily. The BDD made me suicidal.”

Treatment: what works?

Many patients present in non-psychiatric settings, such as dermatology and cosmetic surgery settings.6 Although no one can predict how a given patient will respond to dermatological or surgical treatment, these treatments are unlikely to be successful and may even make the patient’s condition worse.1 7 It is vital that if doctors suspect that patients have BDD that they refer them to a psychiatrist, as available psychiatric treatments have been shown to work.

Selective serotonin reuptake inhibitors

The emergence of selective serotonin reuptake inhibitors (SSRIs) in the treatment of BDD has helped to revolutionise management. SSRIs are effective for most people with BDD.28 Two thirds of patients with BDD reported a decrease in symptoms after taking SSRIs. Relapse rate is high after stopping SSRIs, signifying that long term treatment may be necessary.7

Cognitive behaviour therapy

Cognitive behaviour therapy (CBT) is used in conjunction with SSRIs, or sometimes simply alone. Due to the similarities between BDD and OCD, the same CBT techniques that are so successful in treating OCD are also employed successfully in treating BDD. It has been proved that after CBT there is a significant decrease in preoccupations and time engaged in compulsive behaviours in patients with BDD. One such study showed that 82% of symptoms in patients with BDD significantly decreased (and the disorder eliminated) after CBT treatment. Further detailed treatment studies are needed to highlight the optimum treatment for BDD sufferers. As with many conditions, different treatments succeed for different people.

Simon Clausen, preregistration house office, Leeds General Infirmary
Email: spclausen@doctors.org.uk


studentBMJ 2005;13:133-176 April ISSN 0966-6494

1. Phillips KA. The broken mirror: understanding and treating body dysmorphic disorder. Oxford: Oxford University Press, 1996.
2. Cotterill JA. Body dysmorphic disorder. Dermatol Clin 1996;14:457-63.
3. Bohne A, Keuthen NJ, Wilhelm S, Deckersbach T, Jenike MA. Prevalence of symptoms of body dysmorphic disorder and its correlates: a crosscultural comparison. Psychosomatics 2002;43:486-90.
4. Phillips KA, Diaz S. Gender differences in body dysmorphic disorder. J Nerv Ment Dis 1997;185:570-7.
5. Grant JE, Kim SW, Eckert ED. Body dysmorphic disorder in patients with anorexia nervosa: prevalence, clinical features, and delusionality of body image. Int J Eat Disord 2002;32:291-300.
6. Phillips KA, Dufresne Jr RG. Body dysmorphic disorder: a guide for dermatologists and cosmetic surgeons. Am J Clin Dermatol 2000;1:235-43.
7. Phillips KA, Albertini RS, Siniscalchi JM, Khan A, Robinson M. Effectiveness of pharmacotherapy for body dysmorphic disorder: a chart-review study. J Clin Psychiatry 2001;62:721-7.
8. Heimann SW. SSRI for body dysmorphic disorder. J Am Acad Child Adolesc Psychiatry 1997;36:868.
9. Rosen JC, Reiter J, Orosan P. Cognitivebehavioral body image therapy for body dysmorphic disorder. J Consult Clin Psychol 1995;63:263-9 [Correction appeared in J Consult Clin Psychol 1995;63:437].

       

           

	EDUCATION Body dysmorphic disorder: through a glass darkly       Simon Clausen (April 2005)
	Ray Indraneal (April 29, 2005)       SHO Psychiatry, All Birmingham rotationIndraneal.Ray@bsmht.nhs.uk
	Having read this article about this interesting and often overlooked condition I felt that a few important points needed to be raised. The first is that the actual strength of the belief in the deformity is key to understanding the nature of the diagnosis and the effect it may have on the patients life. It is important to assess whether the belief is delusional, overvalued or obsessional as these all have diagnostic significance. The second point is that these patients require a thorough risk assessment . I recently saw a patient who was actively suicidal due to his percieved jaw deformity. It should be noted also that some patients are so desperate to correct percieved deformities that they may resort to DIY procedures, with obvious horrific consequences.