Body Dysmorphic Disorder (BDD): Prevalence, Features and Management

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08/02/20 Psychology Reference this

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 Body Dysmorphic Disorder (BDD) is characterized as a preoccupation with an imagined or slight defect in appearance. (Hartmann, Blashill, Greenberg, Wilhelm, 2014). Individuals believe they look ugly or abnormal which causes them distress and impairs their ability to function with their day to day life. BDD was first recognized in the American Diagnostic and Statistical Manuel of DSM III-R in 1987. It is considered to be a new clinical phenomenon, but research made by Italian physician and psychical researcher, Enrico “Henry” Morselli (1891), shows 80 patients with similar symptoms of BDD. He described it as dysmorphophobia, where dysmorphia means ugliness in Greek. “When one of these ideas occupies someone’s attention repeatedly on the same day, and aggressively and persistently returns to monopolise his attention, refusing to remit by any conscious effort; and when in particular the emotion accompanying it becomes one of fear, distress, anxiety, and anguish, compelling the individual to modify his behaviour and to act in a pre-determined and fixed way, then the psychological phenomena has gone beyond the bounds of normal, and may validly be considered to have entered the realm of psychopathology.” (Morselli, 1891)

Prevalence

Body Dysmorphic Disorder usually begins in adolescence or early adulthood. The majority of patients in clinical research have never been married or are unemployed. Body Dysmorphic Disorder is as common in men as it is in women. According to data from the DSM-5, the occurrence of BDD in women is 2.2% and 2.5% in males. However, men and women have different areas of concern. Women tend to fixate on their hips, skin, and hide their insecurities with makeup. Whereas men are concerned with their muscularity, (muscular dysmorphia), genitals, and hair. Women are more likely to have other diagnostics such as bulimia nervosa, whereas men will tend to abuse alcohol. (Olivardia, 2004).

Etiology

Research suggest that BDD is caused between biological predisposing factors and environmental stressors. Studies conducted on twins resulted that 42%-44% of BDD symptoms were caused by genetic factors, while the remaining were non-shared environmental influences. No specific risk genes have been identified because no studies have been made yet. There is infrequent environmental factor research since most studies had methodological limitations. Specific environmental factors remain unknown but some suggested factors, such as childhood abuse, peer teasing, and peer victimization, have been suggested to impact the development of body dysmorphic disorder. (Krebs, Fernandez de la Cruz, Mataix-Cols. 2017).

Clinical Features

Appearance Preoccupations

Any area of the body can be the focus of preoccupation. The common areas of concern for people with BDD are skin (73%), hair (56%), and nose (37%). On average, 5 to 7 different body parts can be a person with BDD preoccupation in their lifespan. About 40% of individuals with BDD constantly think about their disliked body parts for 3 to 8 hours per day and 25% thinking about it more than 8 hours per day. (Bjornsson, Didie, Phillips, 2010). BDD preoccupations are time consuming and cause distress. Most patients are delusional and do not recognize that their flaws are nonexistent or minimal. Their constant fixation on their perceived flaw are stemmed from low self-esteem, shame embarrassment, and fear. A majority of patients believe that others stare or mock them for their flaws. (Phillips, 2011). Having repetitive thoughts of their “defect” can affect their daily life by causing them to not want to engage socially or go out. This can affect their relationships and careers.

Repetitive Behavior

Individuals with BDD tend to conduct repetitive, compulsive behaviors that focus on examining, improving, minimizing, or hide their flaw. Common behaviors include mirror checking, comparing others, excessive grooming, frequent clothes changing, reassurance seeking, skin picking, and eating a restricted diet. Behaviors like these are difficult to control and can occur for hours or days. (Phillips, 2004).

Comorbidity

Most patients with BDD may also have a co-occurring mental illness. Common ones include: major depressive disorder, social phobia, OCD, or a substance use disorder. A majority of patients most often have avoidant personality disorder or another personality disorder. (Phillips, 2011).

Diagnosis

 In the DSM-IV-TR, BDD was considered to be under the somatoform disorders and the diagnostic criteria includes the following:

  • Preoccupation with an imagined defect in appearance. If a slight physical anomaly is present, the person’s concern is markedly excessive.
  • The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  • The preoccupation is not better accounted for by another mental disorder (e.g., dissatisfaction with body shape and size in anorexia nervosa). (DSM-IV-R, 1994).

In the Diagnostic and Statistical Manuel of Mental Disorders – Fifth Edition (DSM-5; American Psychiatric Association, 2013) BDD placed in the Obsessive-Compulsive Related Disorders category. The current criteria for the disorder include muscle dysmorphia as a specifier. The delusional and nondelusional variants of BDD have been combined into a single disorder with insight being a specifier, and the delusional variant has been removed in the psychosis section. (Hartmann et al., 2014) A new criteria was also added in the DSM-5:

  • Repetitive Behaviors: an individual must perform repetitive, compulsive behavior focusing on their preoccupation. (constant mirror checking, grooming to fix their perceived flaw, etc.)

Treatment

People with BDD tend to often avoid treatment due to feelings of shame, stigma, skepticism about treatment and financial concerns. When they do seek treatment, they often seek surgical, dermatological, or other non-psychiatric interventions, although these types of treatment may worsen BDD symptoms. (Hartmann et al., 2014). Although treatment research is still limited, serotonin reuptake inhibitors (SRIs) and cognitive-behavioral therapy (CBT) are currently the treatments of choice. CBT uses exposure with response prevention (E/RP) as a main therapeutic strategy. E/RP exposes an individual to confront a fear (e.g, mirrors, social situations) and to resist the urge of wanting to do a safety-seeking behavior (e.g, applying excessive makeup, camouflaging). Other techniques used in CBT are cognitive restructuring, mirror retraining, and attention training. Different types of SRIs have been used to treat BDD such as fluoxetine, fluvoxamine, citalopram, escitalopram, and clomipramine. Studies made using the same medicine for different amount of time showed that 40% of the patients who were on the medication for a short amount of time relapsed, compared to the 18% of patients who were on a continuous amount of time. This concluded that patients must be on medication for a long time to reduce the likelihood of relapse occurring. (Krebs et al., 2017).

Conclusion

Body Dysmorphic Disorder is considered to be a relevantly new disorder. BDD is considered to be categorized under OCD and related disorders but it is often misdiagnosed with eating disorders since they share similar symptoms. Although there is research that dates back from more than 100 years ago that describes similar symptoms to BDD, it was not recognized in the DSM until 1980. People with BDD believe they are ugly or look abnormal due to an imagined or slight anomaly one might have. This affects an individual’s daily life by having repetitive thoughts and behaviors focused on their flaw that are hard to resist or control. BDD is a common illness found in men as it is in women. Although biological and environmental aspects may be factors in the development of BDD, there is still research being conducted to find specific causes of BDD and how to treat it. Cognitive behavior therapy and serotonin reuptake inhibitors are the two effective methods of treatment for BDD.

References:

  • Olivardia, R. (2004). Body Dysmorphic Disorder. In J. K, Thompson (Ed.), Handbook of Eating Disorders and Obesity (pp. 542-558). Hoboken, NJ. John Wiley & Sons.
  • Hartmann, A.S., Blashill, A.J., Greenberg, J.L., Wilhelm, S. (2014) Body Dysmorphic Disorder. In E. A. Storch & D. McKay (Eds.), Obsessive-Compulsive Disorder and Its Spectrtum: A Life-Span Approach (pp. 141-162). Washington, DC. American Psychological Association.
  • Morselli, E. History of Body Dysmorphic Disorder. Retrieved from https://bddfoundation.org/resources/history-of-bdd/
  • Krebs, G., Fernandez de La Cruz, L., Mataix-Cols, M. (2017, Aug. 20). Recent Advances in Understanding and Managing Body Dysmorphic Disorder. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5566091/
  • Phillips, K.A (2011) Body Image and Body Dysmorphic Disorder. In T. F. Cash & L. Smolak (eds.) Body Image: A Handbook of Science, Practice, and Prevention. (pp. 305-313). New York. Guilford Press.
  • Phillips, K. A. (2004, February 3). Body Dysmorphic Disorder: Recognizing and Treating Imagined Ugliness.  Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1414653/
  • Bjornsson, A. D., Didie, E. R., Phillips, K. A. (2010, June 12). Body Dysmorphic Disorder. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3181960/
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