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Body Dysmorphic Disorder
April 27, 2011
Body Dysmorphic Disorder (BDD) is a chronic, debilitating, and often misunderstood mental health problem that affects many individuals. Also known as dysmorphobia, body dysmorphic disorder has been seen across continents for centuries, and is considered a relatively common disorder. However, BDD is unfortunately under-recognized and under-diagnosed. This paper will explain the features of body dysmorphic disorder, as well as explore the prevalence rates and treatments for this impairing disorder (Phillips and Crino).
Diagnosing Body Dysmorphic Disorder
Body Dysmorphic Disorder is currently classified in the fourth edition of the Diagnostic and Statistical Manual of Mental disorders as a separate disorder in the somatoform section. According to the DSM-IV, there are three criteria that a patient must meet in order to be diagnosed with BDD. First, their must be “a preoccupation with an imagined defect in appearance; if a slight physical anomaly is present, the persons concern is markedly excessive.” Next, "The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.” And lastly, “it cannot be better accounted for by another mental disorder, such as anorexia nervosa.” Individuals suffer in many ways from BDD. Primarily, they are preoccupied by intrusive thoughts that concern an abnormality in some aspect of their appearance. They often believe that some aspect of their body is unattractive, deformed, ugly, when this perceived flaw is often not present, or minimal (Phillips and Crino). Patients often complain of being “tortured” by their distress, and are unable to resolve their concern. The most common complaints are of facial flaws, including wrinkles, spots, scars, acne, paleness, redness, swelling, facial asymmetry or disproportion, or excessive facial hair. It is also common to be overly concerned with the shape and size of the nose, eyes, eyebrows, eyelids, ears, mouth, lips, teeth, jaw, chin, cheeks, or head. Although face complaints are most common, any part of the body can be the cause of concern. For example, the genital area, breasts, buttocks, abdomen, arms, hands, feet, legs, hips, shoulders, spine, and skin are also common (Phillips 1991). Although it is possible to only be concerned with one body area, a study done by Phillips et al. found that the average number of areas of excessive concern for patients is between 5 and 7 (Phillips, Menard).
There are many common behaviors that patients frequently experience. According to Professor Schlundt, patients often are overcome with compulsive mirror checking, repeatedly looking at their perceived flaws. On the other hand, sometimes individuals are unable to look at their own reflection, out of fear of seeing their flaw. In addition, patients can experience compulsive skin touching or skin picking, as well as excessive grooming behaviors. Individuals suffer from a constant need for reassurance from friends and family, as well as obsessions with plastic surgeries (Schlundt). In extreme cases, patients with body dysmorphic disorder can lead themselves into complete social isolation, and all patients suffer from functional impairment. In a study of 200 body dysmorphic disorder patients, 36 percent of subjects missed at least one week of work within the past month, and 32 percent of subjects missed one week of school within the past month due to their disorder. Furthermore, 11 percent had even dropped out of school permanently because of the disorder. Over 98 percent of patients had experienced significant impairments in social functioning (Phillips, Menard). Although these numbers are alarmingly high, 134 subjects in the study were already receiving mental health treatment, showing that the true results may even be higher.
In addition to functional impairment, many patients also suffer from other mental disorders in conjunction with body dysmorphic disorder. Depression is the most common associated disorder. According to Phillips, the depression associated is caused by the body dysmorphic disorder. In addition, obsessive-compulsive disorder is often associated with body dysmorphic disorder. In a study carried out by Phillips, over 35% of all subjects with body dysmorphic disorder experienced obsessive compulsions. In a different study of 165 patients with a diagnosed anxiety disorder, 6.7 % of patients exhibited lifetime criteria for body dysmorphic disorder (Otto). In addition, body dysmorphic patients often experience social avoidance, isolation, introversion, avoidant personality disorder, shame, and low-self esteem (Phillips 1991).
Body dysmorphic disorder usually goes unrecognized and undiagnosed, however, it is expected to be relatively common. Most studies report that current rates of reported BDD are between 0.7% and 1.1%, however rates are expected to be much higher because patients are often hesitant to report their disorder. In a study done by Otto on 976 women aged 36-44, the prevalence rate was found to be 0.7%. however in a separate study of 258 college students, 28% met all criteria for the disorder, with 46% reporting some preoccupation with their appearance. Most studies report a similar ratio of men and women sufferers, with this specific study finding 1.3:1 women to men ratio (Phillips 1991). Astoundingly, in the population of patients seeking cosmetic surgery, rates of body dysmorphic disorder have been reported in 6%-15% of patients. In addition, 9-12% of patients seen by dermatologists who see dermatologists frequently have body dysmorphic disorder. (Phillips and Crino). This disorder typically presents itself in late adolescence, with Otto’s study finding an average age of onset of 20.1 years old (Otto). It is obvious that many more studies are necessary to explore the true prevalence of this disorder.
Research shows that the best treatments for body dysmorphic disorder are cognitive behavioral therapy and pharmacotherapy. In a study randomly assigning 54 females with BDD to cognitive behavioral therapy or a control group, symptoms decreased significantly in the treated group, and were reported to be eliminated 82% of the time. In a later study conducted by Veale et al., BDD patients were randomly assigned once again to therapy or a control group, and after 12 weeks of treatment 78% of patients were rated as having absent BDD (Phillips and Crino). In addition to behavioral therapy, pharmacotherapy has been explored as a treatment for BDD. Preliminary research shows that selective reuptake inhibitors (SRI’s) are the most effective drug in treating this disorder. In a retrospective study done on 50 patients, it was found that selective reuptake inhibitors were more effective in eliminating symptoms than antidepressants (Phillips and Crino). SRI’s have been found to overall improve insight as well as reduce stress and the time occupied by defect-related compulsions. In the first controlled pharmacotherapy trial for BDD, 40 patients took part in a double blind cross-over study, evaluating the difference between clomipramine and desipramine as treatments. 65% of patients responded to clomipramine, whereas 35% of patients responded to desipramine. This shows the incoherence of effectiveness of SRI’s on body dysmorphic disorder (Phillips and Crino). In another study of 90 patients, 63.2% of patients receiving a SRI experienced reduced symptoms. However, with the discontinuation of the medicine, 83.8% of patients relapsed. This study once again sited the most improved symptoms through the usage of clomipramine (Phillips, Albertini, Siniscalchi). All in all, it has been found that the most effective treatment is reached when pharmacologic treatment including SRI’s is used in conjunction with behavioral therapy.
Although relatively common, body dysmorphic disorder is an unknown disability to many. It often goes undiagnosed, and many individuals suffer from the debilitating symptoms it carries. Characterized by a preoccupation with an imagined defect in appearance, this disorder often takes over individual’s lives, causing great distress in their daily functioning. Although the prevalence rates are mostly unknown and the disorder often goes unreported, recent studies cite that approximately 1.0 percent of the population report suffering from this disorder. Although not greatly explored, treatment options are available for this disorder. The most researched treatments are cognitive behavioral therapy, and pharmacotherapy, specifically selective reuptake inhibitors. The most effective way to treat body dysmorphic disorder is through a combination of both of these treatments. It is obvious that more extensive research is necessary on this subject. It is a widely unknown disorder, and if more people are aware of its characteristics, proper diagnosis can be improved. In addition, this will lead to more research on effective treatments for the symptoms of body dysmorphic disorder. There are many individuals suffering that need help – and with further research, this can become possible.
Otto, M., Wilhelm, S., Cohen, L., Harlow, B. (2001). Prevalence of body dysmorphic
disorder in a community sample of women. American Journal of Psychiatry. 158(2061).
Phillips, K. (1991). Body dysmorphic disorder: the distress of imagined ugliness.
American Journal of Psychiatry. 148(1138).
Phillips, K., Albertini, R., Siniscalchi, J., Khan, A., Robinson, M. (2001). Effectiveness of
pharmacotherapy for body dysmorphic disorder: a chart-review study.
Journal of Clinical Psychiatry. 62(9).
Phillips, K., Crino, R. (2001). Body dysmorphic disorder. Current Opinion in
Phillips, K., Menard, W., Fay, C., Weisberg, R. (2005). Demographic characteristics,
phenomenology, comorbidity, and family history in 200 individuals with
body dysmorphic disorder. The Academy of Psychosomatic Medicine. 46 (317).
Schlundt, D. (2011). Muscle Dysmorphic Disorder. Psychology of Eating Disorders
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