Body dysmorphic disorder (BDD) is a mental disorder characterized by an obsessive preoccupation that some aspect of one's own appearance is severely flawed and warrants exceptional measures to hide or fix it. In BDD's delusional variant, the flaw is imagined. If the flaw is actual, its importance is severely exaggerated. Either way, one's thoughts about it are pervasive and intrusive, occupying up to several hours a day. The DSM-5 categorizes BDD in the obsessive-compulsive spectrum, and distinguishes it from anorexia nervosa.
BDD estimated to affect up to 2.4% of the population. It usually starts during adolescence, and affects men and women roughly equally. The BDD subtype muscle dysmorphia, perceiving the body as too small, affects mostly males. Besides thinking about it, one repetitively checks and compares the perceived flaw, and can adopt unusual routines to avoid social contact that exposes it. Fearing the stigma of vanity, one usually hides the preoccupation. Commonly unsuspected even by psychiatrists, BDD has been greatly underdiagnosed. Severely impairing quality of life via educational and occupational dysfunction and social isolation, BDD involves especially high rates of suicidal ideation and suicide attempts.
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Signs and symptoms
Whereas vanity concerns preoccupation with aggrandizing the appearance, BDD is compulsion to merely normalize the appearance. Although delusional in about one of three cases, the appearance concern is usually an overvalued idea. Individuals suffering from BDD tend to preoccupy over minimal or non-existent flaws in their appearance. They may view themselves as deformed or unattractive, generally focusing on the face, hair, and other areas of the body such as the stomach, thighs, and hips. Any area can be the preoccupation, but on average, people with BDD tend to focus on 5 to 7 different body parts. Examining their appearance multiple times a day is a regular occurrence and can take up to anywhere between 3 and 8 hours on a daily basis. Common behaviors that are displayed include frequent mirror checking and/or avoiding, outfit changing, skin picking, excessive grooming, and restrictive eating. Victims of BDD often identify with feelings of low self-esteem, shame, and unworthiness. Cognitive testing and neuroimaging suggest both a bias toward detailed visual analysis and a tendency toward emotional hyperarousal.
Via BDD, some persons experience delusions that others are covertly pointing out their flaws. BDD can prompt a quest for dermatological treatment or cosmetic surgery, which interventions typically do not resolve the distress. On the other hand, attempts at self-treatment can create lesions where none previously existed. BDD shares features with obsessive-compulsive disorder, but involves more depression and social avoidance. BDD often associates with social anxiety disorder.
But most generally, one experiencing BDD ruminates over the perceived bodily defect up to several hours daily, uses either social avoidance or camouflaging with cosmetics or apparel, repetitively checks the appearance, compares it to that of other persons, and might often seek verbal reassurances. BDD's severity can wax and wane, and flareups tend to yield absences from school, work, or socializing, sometimes leading to protracted social isolation, with some becoming housebound for extended periods. The distress of BDD tends to exceed that of either major depressive disorder or type-2 diabetes, and rates of suicidal ideation and attempts are especially high.
Quality of life
BDD usually decreases an individual's quality of life to a noticeable degree, social impairment being the greatest. Those with BDD may engage in little to no social activities, avoid meeting new people, and find themselves distancing away from family and friends. A main reason behind this is the ever-present fear of the imagined imperfection being noticed and pointed out. Most people also experience a decrease in academic and/or occupational performance due to a lack of concentration, motivation, and productivity. In a sample study of 500 individuals with BDD, 11% dropped out of school and 36% did not go to work for at least a week due to BDD symptoms.
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Cause
As with most mental disorders, BDD's causation is likely intricate, altogether biopsychosocial, through an interaction of multiple factors, including genetic, developmental, psychological, social, and cultural. BDD can occur at any age but often develops during early adolescence and throughout puberty, when a person's body is experiencing the most changes (physically). Many patients trace their problem to some form of emotional trauma they experienced, such as sexual abuse, parental neglect, and being teased or bullied as a child. Research findings suggest that the disorder can affect both genders equally, but clinical samples that have been collected in the past show that BDD may be more common among women than in men. Studies also found a reoccurring pattern among the individuals suffering from BDD: they are usually single, unemployed, and likely to be or have been divorced. About one percent of Americans suffer from BDD. Patients with BDD are often found to struggle with other mental disorders as well, the most common being depression and anxiety. Social phobia, obsessive-compulsive disorder, substance abuse, and/or personality disorders are also prevalent in those with BDD. Although there the number of clinical studies done on body dysmorphia is lacking, available data suggests that the disorder is chronic, often exhibiting waxing and waning symptoms. Though twin studies into BDD are few, one estimated its heritability at 43%, although BDD's causation may involve introversion, negative body image, perfectionism, heightened aesthetic sensitivity, and childhood abuse and neglect.
Diagnosis
Estimates of prevalence and gender distribution have varied widely via discrepancies in diagnosis and reporting. In American psychiatry, BDD gained diagnostic criteria in the DSM-IV, but clinicians' knowledge of it, especially among general practitioners, is constricted. Meanwhile, the shame that persons feel about having the bodily concern, and fearing the stigma of vanity, hinders recognition. It is common for BDD to be misunderstood and misdiagnosed as a social-anxiety disorder or obsessive-compulsive disorder (OCD), as all of these mental illnesses share common traits and symptoms. BDD may also be mistaken for major depressive disorder or social phobia. Cases of BDD should be inquired about and diagnosed early on, as it can have dangerous effects and consequences on an individual's emotional, mental, and physical health if left untreated. Correct diagnosis calls for specialized questioning and correlation with emotional distress or social dysfunction. In order for people to receive accurate diagnosis and appropriate treatment, patients must specifically address and be transparent with their concerns of their appearance when speaking to a doctor and/or mental health professional. Estimates place the Body Dysmorphic Disorder Questionnaire's sensitivity at 100% (0% false negatives) and specificity at 92.5% (7.5% false positives).
Treatment
There isn't a wide range of available treatment options for BDD yet, as research is still lacking. However, anti-depressant medication, such as serotonin reuptake inhibitors (SRIs), and cognitive-behavioral therapy (CBT) are considered to be effective in treating body dysmorphia. SRIs can aid in relieving the obsessive and compulsive traits of BDD, while cognitive-behavioral therapy helps patients to recognize episodes of irrational thinking and alter their negative thinking patterns. Before administering an SRI and/or therapy to a BDD patient, it is important to provide psychoeducation first, such as self-help books and online support sites. Many patients believe that getting plastic surgery or other cosmetic treatments will fix their defects and permanently cure their distorted perception. However, that is rarely the case. Even if cosmetic surgery did modify and correct their presumed flaws, it is likely that the patient will come up with another defect until that one is fixed, and then another one after that, ultimately creating a dangerous and costly cycle of ineffective remedies.
History
In 1886, Enrico Morselli reported a disorder that he termed dysmorphophobia. In 1980, the American Psychiatric Association recognized the disorder, while categorizing it as an atypical somatoform disorder, in the third edition of its Diagnostic and Statistical Manual of Mental Disorders (DSM). Classifying it as a distinct somatoform disorder, the DSM-III's 1987 revision switched the term to body dysmorphic disorder.
Published in 1994, DSM's fourth edition defines BDD as a preoccupation with an imagined or trivial defect in appearance, a preoccupation causing social or occupational dysfunction, and not better explained as another disorder, such as anorexia nervosa. Published in 2013, the DSM-5 shifts BDD to a new category (obsessive-compulsive spectrum), adds operational criteria (such as repetitive behaviors or intrusive thoughts), and notes the subtype muscle dysmorphia (preoccupation that one's body is too small or insufficiently muscular or lean).
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