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Body Dysmorphic Disorder: an Unhealthy Obsession

Sarah Fernandez

December 12, 2010

Introduction

            Though body dysmorphic disorder (BDD) is often under diagnosed, the limelight of Hollywood can identify a prime poster child in the late Michael Jackson.  With a prevalence of 1.7%  in the general population, BDD does not limit itself to impacting one sex,  nor does it limit itself to effecting one socioeconomic class (Rief et al., 2006).  Everyone diagnosed with this disorder has the same uncontrollable obsession with any single or multiple imagined defects in his or her appearance.  Though many with BDD may not be able to afford costly plastic surgeries and must choose other ways to camouflage themselves, others go through great lengths to have a perceived physical flaw fixed.  Most people know at least one individual who has gone under the knife to have plastic surgery work done; however, what are some of the differences in perception between an individual satisfied with one corrective surgery or someone who is completely content with themselves and an individual with BDD?

The DSM IV Definition of Body Dysmorphic Disorder

            According to the DSM IV, a person diagnosed with body dysmorphic disorder must be "preoccupied with an imagined defect in appearance."  This preoccupation often turns out to be more obsessive than one would think based on the insignificance of the physical feature the individual is concerned with.  Nevertheless, the defect causes "clinically significant distress and impairment in social, occupation, or other important areas of functioning."  Finally, in order for BDD to be diagnosed, the physical preoccupation must not be "accounted for by another mental disorder" like Anorexia Nervosa.

Other symptoms of body dysmorphic disorder include:

·         Compulsive mirror checking, glancing in reflective doors, windows and other reflective surfaces.

·         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 whom the person suffering from BDD wishes to resemble.

·         Excessive grooming behaviors: picking, combing hair, plucking eyebrows, shaving, etc.

·         Obsession with plastic surgery or multiple plastic surgeries, with little satisfactory results for the patient.

·         In extreme cases, patients have attempted to perform plastic surgery on themselves, including liposuction and various implants with disastrous results. Patients have even tried to remove undesired features with a knife or other such tool when the center of the concern is on a point, such as a mole or other such feature in the skin.

 

How BDD Effects Those Diagnosed

            Due to the deeply rooted psychological aspects of body dysmorphic disorder, attention has recently been drawn to the fact that symptoms of BDD show up quite early in an individual's lifetime and often remain until death. As one would assume, the insecurities of adolescence and the teenage years is a perfect environment to foster BDD tendencies.  This proves especially true with the overwhelming ability newspaper, TV, and magazine media have in defining what everyone should or should not look like.  Sure enough, two separate studies found 16 years of age to be the average age for BDD onset.  "About 70% of patients experienced onset of BDD before 18 years"(Didie et al, 2010).  Not only does BDD create an unhappy childhood, but it prevents those it effects from completely developing the necessary social skills to properly venture out into the adult world.  "Distressing and time-consuming appearance preoccupations, as well as prominent appearance-related compulsive behaviors" (Didie et al, 2010) quickly replace the desire to go on a date, go to class, or even attend a job interview.  For this reason those previously or currently diagnosed with BDD often have a hard time succeeding in the personal, educational, and occupational realm.  With preoccupation regarding their own physical self, it is often difficult to focus on much else, much less a chemistry exam or work presentation.  Similarly, because individuals with BDD are so unhappy with themselves, they have a higher probability of being divorced or single.  The following two tables indicate the most prevalent, perceived defects in those with BDD as well as the habits they adopt to hide them.

Table 1.

Location of Perceived Defects in BDD (lifetime)

 

Body Part   

Percentage (%) of Patients with Concern*   

Skin  

73  

Hair  

56  

Nose  

37  

Weight  

22  

Stomach  

22  

Breast/chest/nipples  

21  

Eyes  

20  

Thighs  

20  

Teeth  

20  

Legs (overall)  

18  

Body build/bone structure  

16  

Ugly face (general)  

14  

Face size/shape  

12  

Lips  

12  

Buttocks  

12  

Chin  

11  

Eyebrows  

11  

Hips  

11  

Ears  

9  

Arms/wrists  

9  

Waist  

9  

Genitals  

8  

Cheeks/cheekbones  

8  

Calves  

8  

Height  

7  

Head size/shape  

6  

Forehead  

6  

Feet  

6  

Hands  

6  

Jaw  

6  

Mouth  

6  

Back  

6  

Fingers  

5  

Neck  

5  

Shoulders  

3  

Knees  

3  

Toes  

3  

Ankles  

2  

Facial muscles  

1  

 

* The percentages add up to more than 100% because people are usually concerned with more than one aspect of their appearance.

Phillips KA. Understanding Body Dysmorphic Disorder: An Essential Guide. New York, NY: Oxford University Press; 2009. www.oup.com.

Table 2.

[Table]

Common Repetitive Behaviors (compulsions) in BDD

 

Behavior   

Percentage (%) of People with Behavior   

Camouflaging  

91  

With body position/posture  

65  

With clothing  

63  

With makeup  

55  

With hand  

49  

With hair  

49  

With hat  

29  

Comparing disliked body part with others/scrutinizing the appearance of others  

88  

Checking appearance in mirrors and other reflecting surfaces  

87  

Seeking surgery, dermatologic, dental, or other cosmetic treatment  

72  

Excessive grooming (combing hair, applying makeup, shaving, removing hair, etc.)  

59  

Questioning or reassurance-seeking (seeking reassurance about the perceived flaw or attempting to convince others that it's unattractive)  

54  

Touching the perceived flaw  

52  

Excessive clothes changing  

46  

Dieting  

39  

Skin picking to improve appearance  

38  

Tanning to improve a perceived flaw  

22  

Excessive exercise  

21  

Excessive weight lifting  

18  

 

Phillips KA. Understanding Body Dysmorphic Disorder: An Essential Guide. New York, NY: Oxford University Press; 2009. www.oup.com.   

Discussion of Scientific Literature

Study 1

            Because so much is still unknown about the mental interpretations of those with body dysmorphic disorder, an interesting study was conducted in order to "qualitatively explore self perceptions" of those diagnosed with body dysmorphic disorder (Silver et al, 2010).  For this study, eleven diagnosed individuals were observed using a series of interviews during which participants underwent questioning and were asked to draw a self-portrait.  The results from each individual were analyzed collectively with those from the other individuals diagnosed in order to determine if there were any major underlying themes or characteristics.  In conclusion, "the most common theme was increased threat perception resulting in disordered interpersonal relationships. Other themes included the wish for regularity and symmetry in appearance, an idealized childhood self, the duty to look good, and a focus on specific 'defective' features rather than general ugliness"(Silver et al, 2010). 

Evaluation

            This study had an extremely small experimental group, and this makes it difficult to fully accept their conclusion as definite in applying to the wide range of individuals diagnosed with BDD.  The task of drawing a self portrait while experiencing questioning does seem like the classic approach to analyzing those with BDD.  The idea of having the patients draw a picture allows the researchers to view the unhappy caricature the diagnosed view themselves as.  Because it is difficult to draw a broad conclusion from so few test subjects, I think the self-portrait picture in this case means more than the words.

Study 2

            It has often been said that a symmetrical face is statistically picked as the most visually appealing; however, to what extent does symmetry impact the judgments made by an individual diagnosed with BDD.  Though many judge beauty on different features, one research group hypothesized that those with BDD have a better ability to detect symmetry in the faces of those they encounter as well as their own face (Reese et al, 2010).  In this study, the results from twenty individuals with body dysmorphic disorder were compared to those of twenty  normal, undiagnosed individuals and twenty persons with diagnosed OCD.  Each person involved in the study was exposed to a "symmetry detection task" on a laptop.  Testing of face symmetry was done by taking one black and white picture of a male or female face and creating three alternative versions based off the original.  "Each face [was made] perfectly symmetrical (a blend of the normal face and a mirror image of the face), highly symmetrical (a 50% reduction in the difference between the perfectly symmetrical face and the normal face), or less symmetrical (a 50% increase in the difference between the normal face and the perfectly symmetrical face)" (Reese et al, 2010).  The original and the three resulting pictures were then shown, and the individuals being tested were allowed to pick which face was more symmetrical.  During testing, images of ten men and ten women were randomly shown.  No time limit was given for each round.  Reaction times and responses were recorded.  The next phase of study involved the monitoring of symmetry other than that found in the face.  Dot symmetry detection was conducted in order to determine if symmetry in general, rather than that of the face, was perceived better by those with BDD.  Each individual in the three groups was presented with forty dot arrays.  Twenty of the forty arrays were perfectly symmetrical, while the other forty were slightly asymmetrical.  A random presentation of the arrays required the participants to determine symmetry versus asymmetry after each image.  Reaction time was once again recorded though no set time for the study was designated.  Contrary to the initial hypothesis, "individuals with BDD were not significantly better at detecting differences in facial symmetry relative to the other two groups'" nor did they "show a stronger preference for symmetry" in comparison to the other controls(Reese et al, 2010).  The normal control group and the group with BDD had an average reaction time of three to three and a half seconds, whereas the OCD group had an average response time of five seconds.  No significant differences regarding the dot symmetry test resulted among the normal, OCD, and BDD group.  Though the initial hypothesis regarding those with BDD had to be rejected, results from this study did conclude that more symmetrical faces were more often preferred compared to those lacking symmetry.

Evaluation

            This study was set up very well and would seem perfectly fit to find any results that were meant to be found.  Dot symmetry and facial symmetry of varying degrees were tested, and this allowed researchers to observe perception of both faces and objects.  Though the test subject size was low with only twenty diagnosed BDD individuals, this is most likely due to the fact that twenty controls and twenty OCD patients had to be included in the study.  The fact that controls were used better allows whatever data was found from the BDD diagnosed patients to be compared to what would be considered normal.  Likewise, by including the OCD patients, differences in reaction time and opinion can be determined between individuals with both disorders.  Though OCD is said to be somewhat similar to BDD, this study enables us to visualize the differences in perception between OCD and BDD as well as the differences between both diseased groups and the normal group.  Though the initial hypothesis surprisingly had to be rejected by the end of this study, perhaps, if finances allow, a larger control group would generate different results.

Study 3

            Because the ability to detect symmetry in twenty BDD patients was not greater than that of twenty normal, healthy individuals, perhaps a type of delusion can be found in those with BDD.  One study in the Australian and New Zealand Journal of Psychiatry sought to study the extent to which those with BDD experienced delusional thinking.  Fourteen individuals with BDD along with fourteen healthy controls were asked to take the Peters Delusional Inventory (PDI).  The PDI is a 21 question test "which examines the multidimensionality of delusions by examining the dimensions of distress, preoccupation, and conviction."  Three more tests were also taken to asses "fantasy proneness", self-esteem, and "the extent to which beliefs about self-worth are uncertain, conflicting and a source of anxious introspection."  Final analysis of the data indeed indicated that those with BDD have a higher amount of delusional beliefs than their normal control counterparts (Labuschagne et al, 2010).  Lower levels of self esteem and higher levels of fantasy proneness were observed in BDD patients.

Evaluation

            Delusional thinking is the mark of someone with BDD, and this study aptly supports it.  Those with BDD by definition, are individuals who magnify a physical feature to a point at which they can no longer stand it.  This experiment used four different question survey tests in order to determine some common themes among the fourteen BDD patients.  Though this study only included fourteen individuals with BDD, having each one fill out four surveys allowed the researchers to better understand those particular fourteen individuals.  Rather if 56 diagnosed individuals had filled out one survey, yes there would be more data, but the results would be less comprehensive per person.  Researchers would have less of an idea of the whole individual if there were too many more subjects.  In this case, the researchers were choosing quality data over quantity.  A control group was appropriately included for data comparison.

Potential Cures

             Though plastic surgery has become more much more prevalent and acceptable in society, this may not be a good thing for those diagnosed with BDD.  It appears that the availability of such procedures cultivates a deeper obsession in some individuals with a BDD problem.  Table 2 indicates that 72% of the questioned individuals with BDD underwent some sort of surgery or cosmetic treatment.   For example, Jocelyn Wildenstein (now known as the "Cat Woman"), has made herself famous for reportedly spending over four million dollars in plastic surgery costs.  Though she no longer looks as she did before, most believe she looks unrecognizably worse.  Undergoing so many surgeries proves the extent to which some with BDD are willing to go in order to satisfy themselves.  The final outcome also proves that, from the beginning, her desired appearance was completely unrealistic.  Hedi Montag is just one example of an individual driven by the magnifying glass of Hollywood to pursue BDD urges.  Though she began with a single breast augmentation, in procedures to follow she would undergo an additional breast augmentation, brow lift, botox injection, nose job, buttocks augmentation, liposuction, and a series of other invasive plastic surgery procedures.  One study published in the Kaohsiung Journal of Medical Sciences attempted to determine exactly how many individuals out of 817 who had sought cosmetic surgery could be diagnosed with BDD (2010).  The study, conducted after reviewing the medical records of those receiving the surgery, determined that roughly 7.7% of the 817 patients indeed had BDD.  Though this number is not extremely high, approximately 63 individuals with BDD out of 817 total plastic surgery patients did seek solace in plastic surgery.  Another study that sought to indicate the satisfaction of BDD patients receiving cosmetic surgery concluded that the surgeries do not ameliorate the symptoms of BDD.  "The largest study ( n = 250 adults) found that only 7.3% of all cosmetic treatments that were received led to a decrease in concern with the treated body part and overall improvement in BDD"(Phillips et al, 2001).  In fact, some individuals even developed more concerns about their appearance after the operation. Because individuals with BDD unhappy with their plastic surgery outcomes have been known to harass their providers, many surgeons refuse their services to anyone suspected of having BDD (Crerand et al, 2010).  Though body dysmorphic disorder is one that impacts people under the radar, perhaps in the future, therapy can lower those seeking the extreme fixes exemplified by plastic surgery.

            Due to the fact that plastic surgery may not be the best way to cure BDD, other treatments must be used to rid individuals of this relatively undertreated and under diagnosed disease.  One study employed a successful cognitive-behavioral treatment (10 sessions at 50 minutes each) on a thirty-three year old adult male with BDD.  After treatment, this individual reported a reduction in physical concerns and negative thinking.  His BDD symptoms were observed to be less prevalent and overwhelming.  This fostered an "increased optimism about his future"(Wilhelm et al, 2010).  The first phase of the treatment involved a therapist educating the individual about BDD.  Likewise, the therapist sought to identify and make known to the individual the origin of his disorder in relation to his past. Outside therapy sessions, the individual was told to focus on modifying his negative thoughts, decreasing maladaptive coping behaviors, and increasing adaptive behaviors (e.g., hobbies, increased social support and activities)" (Wilhelm et al, 2010).  Further sessions focused on " perceptual retraining exercises." On a daily basis, the individual was "to refrain from negative labeling and from engaging in rituals or avoidance behaviors"(Wilhelm et al, 2010).  And though this made him uncomfortable at first, it soon became an appeasing habit. Rather than focusing on himself and his own physical shortcoming, the patient was taught to focus on the "external stimuli" like the conversation currently going on, or the weather.  During the last of the ten treatment session, the therapist and patient discussed strategies in the event of a relapse into his BDD tendencies.

Summary and Conclusion

            Body dysmorphic disorder may be a disease that only affect a small percentage of the general population, but for those it affects it brings about an unhappy lifestyle.  Delusions marked by constant preoccupation with self-worth and appearance rule each action of every day.  And though those with BDD are observed to have no additional ability to detect facial symmetry, a defined beauty by most, they still develop animosity towards their own appearance.  Though it is often difficult to diagnose, treat, and cure an illness like body dysmorphic disorder, it can be done.  Because plastic surgery has failed as a cure and often worsens BDD symptoms, perhaps therapy is the best answer to such a consuming disorder.  Further studies should be done to assess more treatment options for those with body dysmorphic disorder; multiple individuals diagnosed should be tested as well in order to determine which treatment is best for the widest range of BDD patients.

 

 

 

 

 

 

 

                                                            Literature Cited

Crerand, C., & Sarwer, D. (2010). Cosmetic Treatments and Body Dysmorphic Disorder. Psychiatric Annals , 40 (7), 344-349.

Kelly, M., Didie, E., & Phillips, K. (2010). Clinical Features of Body Dysmorphic Disorder. 40 (7), 310-317.

Labuschagne, I., Castle, D., Dunai, J., Kyrios, M., & Rossell, S. (2010). An examination of delusional thinking and cognitive styles in body dysmorphic disorder. Australian and New Zealand Journal of Psychiatry , 44 (8), 706-712.

Lai, C., Lee, S., Yeh, Y., & Chen, C. (2010). Body Dysmorphic Disorder in Patients with Cosmetic Surgery. Kaohsiung Journal of Medical Sciences , 26 (9), 478-482.

Phillips KA, Grant JE, Siniscalchi J, Albertini RS . Surgical and nonpsychiatric medical treatment of patients with body dysmorphic disorder. Psychosomatics. 2001; 42(6):504-510.

 

Reese, H., McNally, R., & Sabine, W. (2010). Facial Asymmetry Detection in Patients with Body Dysmorphic Disorder. Behavior Research and Therapy , 48 (9), 936-940.

Rief W, Buhlmann U, Wilhelm S, Borkenhagen A, Brahler E. The prevalence of body dysmorphic disorder: a population-based survey. Psychol Med 2006; 36:877–885.

Silver, J., Reavey, P., & Fineberg, N. (2010). How do people with body dysmorphic disorder view themselves? A thematic analysis. International Journal of Psychiatry and Clinical Practice , 14 (3), 190-197.

Wilhelm, S., Buhlmann, U., Hayward, L., Greenberg, J., & Dimaite, R. A Cognitive-Behavioral Treatment Approach for Body Dysmorphic Disorder. Cognitive and Behavioral Practice , 17 (3), 241-247.

 

 

 

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