With plastic surgeons and dermatologists treating a considerable percentage of patients presenting with body dysmorphic disorder, Dana S Saade, MD, and Neelam A Vashi, MD, provide an overview of this often unrecognised and underdiagnosed condition
BODY DYSMORPHIC DISORDER (BDD) IS A chronic and complex disease, increasingly common but relatively unrecognised. Described for a century now, it is still being studied, redefined, and reclassified. With the development of obsessions over appearance and often nonexistent flaws, BDD associated preoccupations throw patients into anxiety, stress, fixations, and impulses to fix these flaws. This relentless pursuit of physical perfection leads to a downhill spiral of psychological despair and sometimes even suicide. This review offers a general overview of BDD and familiarises the reader about this debilitating disease. It discusses its history, aetiology, classification, and symptoms. Screening questionnaires are also presented and a quick review of therapy options is discussed at the end.
History and classification
One of the first descriptions of body dysmorphic disorder dates to 1886 by Italian psychiatrist Enrico Morselli. He coined the term ‘dysmorphophobia’, etymologically traced back to the Greek term dysmorphia meaning ‘misshapenness and ugliness’1. Later, BDD was described by the French psychiatrist Pierre Janet calling it ‘l’obsession de la honte du corps’, or ‘obsessions of the shame of the body’2. Sigmund Freud popularised it by psychoanalysing the ‘wolf man’, a Russian aristocrat that was fixated on his nose believing it had deformities: ‘blackheads, swelling and wounds’3. Ladee defined this condition as ‘dermatologic hypochondriasis’, describing patients neglecting their lives in order to focus on their body appearances4.
It was not until 1980 that dysmorphophobia was introduced in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM) III under the atypical somatoform disorder5. Later, in 1987, it was designated as ‘body dysmorphic disorder’ with clear diagnostic criteria in the DSM III-R5. In the latest DSM V, BDD was reclassified under the ‘Obsessive Compulsive and related disorders’ category with specifics to the degree of insight6. The International Classification of Diseases (ICD-10) has it classified as a ‘hypochondriacal disorder’.
BDD is a common disorder; prevalence reports range from 0.7% to 2.4% in the general population7–11. However, in a dermatologic setting or a plastic surgery setting, where patients are coming in with bodily concerns, the prevalence is much higher. In a systematic review looking at studies done on BDD in such clinical scenarios, it was found that 15.04% of patients had BDD (range 2.21–56.67%) in the specialty of plastic surgery and 12.65% of patients had BDD (range 4.52–35.16%) in dermatology12. It should be noted that most of these numbers underestimate the actual number of patients suffering from BDD given patient hesitation to discuss their symptoms, the delusional nature of many afflicted, the difficulty of diagnosis, and overall unawareness among medical professionals.
BDD affects both men and women. Women make up the majority of patients, >70% of cases in most studies reported in the literature12. Nevertheless, there are a few studies noting a higher male proportion of BDD13–15. Particularly, muscle dysmorphia (described later) usually affects males16–18.
Many BDD patients describe their first symptoms in their 3rd to 4th decade of life, with a high proportion >65% before the age of eighteen19. The age range is wide, there have been reports of BDD as young as 4 years old; however, the mean age of onset is around 12 years of age19,20.
According to the DSM V, the following criterion need to be met to fulfil a diagnosis21:
- Preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others
- At some point during the course of the disorder, repetitive behaviours (e.g. mirror checking, excessive grooming, skin pricking, or reassurance seeking) or mental acts (e.g. comparing their appearance with that of others) in response to appearance concerns have been performed
- The preoccupation is not attributable to any other medical condition
- The appearance preoccupations are not better accounted for by concerns with body fat or weight.
- One scenario that needs to be specified according to the DSM V criteria is muscle dysmorphia or the belief that one’s body is not muscular enough. Insight is another important diagnostic criterion21. As previously mentioned, BDD can fall under the delusional umbrella. Insight can range in the spectrum of good/ fair, poor, and absent21:
- Good or fair insight: the individual recognises that BDD beliefs are definitely or probably not true, or that they may or may not be true
- Poor insight: the individual thinks BDD beliefs are probably correct
- Absent insight (i.e. delusional beliefs about appearance): the individual is completely convinced BDD beliefs are true.
In more detail, patients with BDD are preoccupied with a defect that is not perceived by others. This defect is minimal or even nonexistent. It consumes their time and develops into an obsession. These patients actively think about their defect for up to 3 to 8 hours a day22. Their main areas of concern are usually of the face, particularly the skin (73%), hair (56%) and nose (37%)23. For example, skin complaints include wrinkles, acne, pigmentation problems, scars and marks. Hair complaints include thinning of hair, excess hairs, and even hair that is ‘too curly’22. Patients are often concerned with multiple body parts at the same time and these body parts change over time. On average, during the course of their disorder, BDD patients complain of 5–7 different body parts23. Muscle dysmorphia is another perceived defect namely in men, where they deem their body not built enough and/or not muscular enough. Men, more broadly, also complain of their genitals, weight, and hair24.
These concerns lead to compulsions. They are time-consuming, repetitive, and uncontrollable in the aim to relieve, fix, and correct the distressing defect. Among those are constant mirror checking, make-up camouflaging, and reassurance seeking behaviour from their friends/family or physician25.
This combination of obsession and compulsions lead to impairment in patients’ daily functioning causing significant distress and anxiety22. The severity of the impairment lies within a spectrum. Some patients are able to lead a seemingly normal life, while others avoid all social interaction5,7. This avoidance behaviour is adopted in order to hide their ‘ugly’ defect(s) from their environment. Some are unable to maintain school, work or familial commitments23.
Insight or level of delusion regarding their disorder lies in a spectrum and the patient can progress from one end to the other7. Using the ‘Brown Assessment of Belief Scale,’ up to 39% of BDD patients were delusional and 72% had poor or absent insight7,26,27. These patients are firmly attached to their belief, refusing to accept any other explanation other than that they have a physical flaw. They also have referential thinking, meaning that they believe that people around them take notice of their defect and view them in a negative way, even mocking them27.
BDD patients often have other comorbid mental disorders. Gunstad et al. looked at axis I comorbidities with BDD and found that ‘comorbidity is the rule and not the exception’28. In a lifetime, a BDD patient will likely fulfil the criteria of two or more psychiatric disorders. The most common disorder found was major depressive disorder, followed by social phobia, obsessive-compulsive disorder, and substance abuse28. The earlier the onset of BDD (<18 years), the more association with another psychiatric comorbidity, such as an eating disorder, substance abuse disorder and/or personality disorder19.
BDD follows a long, protracted course, with a mean duration of around 16 years23. Patients can take up to 11 years to seek medical help for their condition29. If not treated adequately in a psychiatric setting, only 9% fully remit after 1 year and 21% partially remit30. Responses are slightly higher if treated appropriately, with only 25% in full remission at 1 year31.
The quality of life of these patients is poor, poorer than other psychiatric patients as it is emotionally, physically, and socially impairing in almost all daily aspects. Patients are unable to maintain school, work, leisure, family and/or personal relationships32. Having a comorbid condition and a longer duration of BDD further negatively impact patients’ lives28.
Body dysmorphic disorder has one the highest suicide rates, attempted or completed, compared to other psychiatric illnesses. Two large studies completed in the US (n=307 and n=200) found a rate of 81% and 78% of suicidal ideation among BDD patients33,34. These same studies found a 24% and 28% rate of suicide attempts. These attempts are 6–23 times higher than reported for the US population34.
Risk factors contributing to suicide in BDD have been studied. Early onset of BDD (<18 years of age) is significantly associated with a history of suicide attempts19. Comorbid conditions such as major depression and other eating disorders or substance abuse disorders have been shown to increase the risk of suicidality33. Others risks include psychiatric hospitalisation, unemployment and disability, single or divorced marital status, and lack of social support34.
Although research on the aetiology of BDD is limited, it is well-recognised that there is an interplay between genetic factors, neuro-physiologic factors, and environmental factors. Twin concordance rates for BDD show that monozygotic twins have around 43% higher rates of BDD than dizygotic twins, indicating that BDD is somewhat heritable through genes35.
The role of serotonin in the pathogenesis of BDD is not fully proven. Its involvement is assumed given the fact that treatment with serotonin reuptake inhibitors (SRIs) is effective in alleviating some of BDD symptoms (discussed later). In addition, one study found decreased density of serotonin transporters in the brains of patients with BDD as compared to controls36. Abnormal brain connectivity and white matter have also been noticed using brain imagining studies37–39.Many environmental factors have been proposed to contribute to BDD’s development and triggering. Particularly, up to 79% of BDD patients report a history of sexual and physical abuse40. Appearance-based teasing and bullying have been shown to contribute to a poorer quality of life of BDD patients41,42. Those with social anxiety and a history of appearance victimisation also have a tendency to develop BDD43.
The secretive nature of BDD makes it difficult to detect even by the most astute clinician. Many tools and screening questionnaires have been developed to aid the clinician in recognising and diagnosing BDD. Proper history taking and looking out for red flags remain an essential part of the medical interview (Table 1). A psychiatric history is paramount and gives a clue into the diagnosis: BDD patients frequently suffer from other comorbidities, namely psychiatric disorders such as mood and eating disorders44. In a study by Sarwer et al., approximately 20% of cosmetic surgery patients reported a mental health history, which was significantly greater than 4% of non-cosmetic plastic surgery patients. Also, 18% of cosmetic surgery patients reported current use of a psychiatric medication, which was also significantly greater than 5% of non-cosmetic surgery patients45. When in doubt or suspicious, proper psychiatric evaluation and referral is recommended.
Multiple self-report questionnaires and scales have been developed for BDD screening within the fields of psychiatry, plastic surgery, and dermatology for use in the clinical setting. Though not all validated, two questionnaires have been shown to have high specificity and sensitivity for the detection of BDD47,48: the Body Dysmorphic Disorder Questionnaire-Dermatology Version ( BDDQ-DV) and The Dysmorphic Concern Questionnaire (DCQ). The Body Dysmorphic Disorder Questionnaire-Dermatology Version (BDDQ-DV) (Figure 1) has a sensitivity of 100% and specificity of 94.7% in the dermatology setting49. It consists of a set of ‘yes/no’ questions with a Likert scale from 1–5 to indicate a range of severity (Figure 1). To screen positive for BDD, patients must report the presence of preoccupation as well as at least moderate (score of 3 or higher) distress or impairment in functioning.
Patients with BDD often present to the dermatologist or plastic surgeon to seek treatment for their defect. However, it is seldom the case that this type of intervention is effective. In a study of 200 patients, treatment was sought by 71.0% and received by 64.0%; however, only 3.6% reported improvement in their BDD symptoms50. A general approach to such patients is presented in Table 2.
Treatment of BDD relies on psychiatric care and medications, mainly selective serotonin reuptake inhibitors (SSRIs). Cognitive behavioural therapy (CBT) has been proven to be efficacious to manage symptoms of BDD. There are currently no randomised controlled studies comparing SSRIs and CBT, to show one’s superiority over the other. The combination of both is recommended for BDD management.
Although no medication is FDA approved for BDD, SSRIs are the first line medication and multiple options are available51. Fluvoxamine, fluoxetine, citalopram and escitalopram have all been shown to be successful to help BDD symptoms including the delusional type: up to 73.3% of patients respond to SSRIs52. There is no study recommending a total duration of treatment, but discontinuation of SSRIs has been complicated by relapse. An estimated 87% of patients relapse within 6 months of stopping their medication.
CBT in BDD has been proven to decrease BDD symptoms since the late 1990s53. Most of the studies describe a regimen of 90 minutes session, 1–5 times a week54. These sessions include cognitive strategies, restructuring patient thoughts, motivational techniques, and exposure and ritual prevention. There are no long-term studies for CBT, but a 12-month follow-up study showed that effects are only somewhat maintained: patients are still susceptible and vulnerable to various stressors55.
BDD is a complex psychiatric disorder that is often debilitating. Despite its prevalence and severity, it is frequently missed in the clinical setting, underdiagnosed and/or under-recognised. The relentless search for bodily perfection and the suicidal risk makes this disorder highly morbid. Awareness of this condition is imperative to help in recognising and treating this condition. Awareness should not only be focused on the treating physicians, dermatologists and plastic surgeons but also should focus on the community at large. BDD patients need to be aware of their condition in order to acknowledge their symptomology and seek medical psychiatric help. Also, family and friends of BDD patients need to know that such a condition exists in order to direct their affected loved ones to proper care. Research into BDD’s aetiology and treatment is currently blooming, hopefully leading to a better understanding and better care for our patients.
Declaration of interest None
Figures 1 © Dana S. Saade
Tables 1-2 © Dana S. Saade
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