body dysmorphic disorder

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Body Dysmorphic Disorder

 

Definition

Body dysmorphic disorder (BDD) is defined by DSM-IV-TR as a condition marked by excessive pre-occupation with an imaginary or minor defect in a facial feature or localized part of the body. The diagnostic criteria specify that the condition must be sufficiently severe to cause a decline in the patient's social, occupational, or educational functioning. The most common cause of this decline is the time lost in obsessing about the "defect"—one study found that 68 percent of patients in a sample of adolescents diagnosed with BDD spent three or more hours every day thinking about the body part or facial feature of concern. DSM-IV assigns BDD to the larger category of somatoform disorders, which are disorders characterized by physical complaints that appear to be medical in origin but that cannot be explained in terms of a physical disease, the results of substance abuse, or by another mental disorder.
The earliest known case of BDD in the medical literature was reported by an Italian physician named Enrique Morselli in 1886, but the disorder was not defined as a formal diagnostic category until DSM-III-R in 1987. The World Health Organization (WHO) did not add BDD to the International Classification of Diseases (ICD) until 1992. The word dysmorphic comes from two Greek words that mean "bad" or "ugly" and "shape" or "form." BDD was previously known as dysmorphophobia.

Description

BDD is characterized by an unusual degree of worry or concern about a specific part of the face or body, rather than the general size or shape of the body. It is distinguished from anorexia nervosa and bulimia nervosa in that patients with eating disorders are preoccupied with their overall weight and body shape. As many as 50 percent of patients diagnosed with BDD undergo plastic surgery to correct their perceived physical defects.
Since the publication of DSM-IV in 1994, some psychiatrists have suggested that there is a subtype of BDD, namely muscle dysmorphia. Muscle dysmorphia is marked by excessive concern with one's muscularity and/or fitness. Persons with muscle dysmorphia spend unusual amounts of time working out in gyms or exercising rather than dieting obsessively or seeking plastic surgery. DSM-IV-TR added references to concern about body build and excessive weight lifting to DSM-IV's description of BDD in order to cover muscle dysmorphia.
BDD and muscle dysmorphia can both be described as disorders resulting from the patient's distorted body image. Body image refers to a person's mental picture of his or her outward appearance, including size, shape, and form. It has two major components: how the person perceives their physical appearance, and how they feel about their body. Significant distortions in self-perception can lead to intense dissatisfaction with one's body and dysfunctional behaviors aimed at improving one's appearance. Some patients with BDD are aware that their concerns are excessive, but others do not have this degree of insight; about 50 percent of patients diagnosed with BDD also meet the criteria for a delusional disorder.
The usual age of onset of BDD is late childhood or early adolescence; the average age of patients diagnosed with the disorder is 17. BDD has a high rate of comorbidity, which means that people diagnosed with the disorder are highly likely to have been diagnosed with another psychiatric disorder—most commonly major depression, social phobia, or obsessive-compulsive disorder (OCD). About 29% of patients with BDD eventually try to commit suicide.
BDD is thought to affect 1-2 percent of the general population in the United States and Canada, although some doctors think that it is underdiagnosed because it coexists so often with depression and other disorders. In addition, patients are often ashamed of grooming rituals and other behaviors associated with BDD, and may avoid telling their doctor about them. BDD is thought to affect men and women equally; however, there are no reliable data as of the early 2000s regarding racial or ethnic differences in the incidence of the disorder.

Causes and symptoms

Causes

The causes of BDD fall into two major categories, neurobiological and psychosocial.
NEUROBIOLOGICAL CAUSES. Research indicates that patients diagnosed with BDD have serotonin levels that are lower than normal. Serotonin is a neurotransmitter—a chemical produced by the brain that helps to transmit nerve impulses across the junctions between nerve cells. Low serotonin levels are associated with depression and other mood disorders.
PSYCHOSOCIAL CAUSES. Another important factor in the development of BDD is the influence of the mass media in developed countries, particularly the role of advertising in spreading images of physically "perfect" men and women. Impressionable children and adolescents absorb the message that anything short of physical perfection is unacceptable. They may then develop distorted perceptions of their own faces and bodies.

Key terms

Body image — A term that refers to a person s inner picture of his or her outward appearance. It has two components: perceptions of the appearance of one's body, and emotional responses to those perceptions.
Delusion — A false belief that is resistant to reason or contrary to actual fact. Common delusions include delusions of persecution, delusions about one s importance (sometimes called delusions of grandeur), or delusions of being controlled by others. In BDD, the delusion is related to the patient's perception of his or her body.
Displacement — A psychological process in which feelings originating from one source are expressed outwardly in terms of concern or preoccupation with an issue or problem that the patient considers more acceptable. In some BDD patients, obsession about the body includes displaced feelings, often related to a history of childhood abuse.
Muscle dysmorphia — A subtype of BDD, described as excessive preoccupation with muscularity and body building to the point of interference with social, educational, or occupational functioning.
Serotonin — A chemical produced by the brain that functions as a neurotransmitter. Low serotonin levels are associated with mood disorders, particularly depression. Medications known as selective serotonin reuptake inhibitors (SSRIs) are used to treat BDD and other disorders characterized by depressed mood.
Somatoform disorders — A group of psychiatric disorders in the DSM-IV-TR classification that are characterized by external physical symptoms or complaints. BDD is classified as a somatoform disorder.
A young person's family of origin also has a powerful influence on his or her vulnerability to BDD. Children whose parents are themselves obsessed with appearance, dieting, and/or body building, or who are highly critical of their children's looks, are at greater risk of developing BDD.
An additional factor in some young people is a history of childhood trauma or abuse. Buried feelings about the abuse or traumatic incident may emerge in the form of obsession about a part of the face or body. This "reassignment" of emotions from the unacknowledged true cause to another issue is called displacement. For example, an adolescent who frequently felt overwhelmed in childhood by physically abusive parents may develop a preoccupation at the high school level with muscular strength and power.

Symptoms

The central symptom of BDD is excessive concern with a specific facial feature or body part. Research indicates that the features most likely to be the focus of the patient's attention are (in order of frequency) complexion flaws (acne, blemishes, scars, wrinkles); hair (on the head or the body, too much or too little); and facial features (size, shape, or lack of symmetry). The patient's concerns may, however, involve other body parts, and may shift over time from one feature to another.
Other symptoms of body dysmorphic disorder include:
  • Ritualistic behavior. Ritualistic behavior refers to actions that the patient performs to manage anxiety and that take up excessive amounts of his or her time. Patients are typically upset if someone or something interferes with or interrupts their ritual. Ritualistic behaviors in BDD may include exercise or makeup routines, assuming specific poses or postures in front of a mirror, etc.
  • Camouflaging the "problem" feature or body part with makeup, hats, or clothing. Camouflaging appears to be the single most common symptom among patients with BDD; it is reported by 94%.
  • Abnormal behavior around mirrors, car bumpers, large windows, or similar reflecting surfaces. A majority of patients diagnosed with BDD frequently check their appearance in mirrors or spend long periods of time doing so. A minority, however, react in the opposite fashion and avoid mirrors whenever possible.
  • Frequent requests for reassurance from others about their appearance.
  • Frequently comparing one's appearance to others.
  • Avoiding activities outside the home, including school and social events.

Diagnosis

The diagnosis of BDD in children or adolescents is often made by physicians in family practice because they are more likely to have developed long-term relationships of trust with young people. At the adult level, it is often specialists in dermatology, cosmetic dentistry, or plastic surgery who may suspect that the patient suffers from BDD because of frequent requests for repeated or unnecessary procedures. Reported rates of BDD among dermatology and cosmetic surgery patients range between 6 and 15 percent. The diagnosis is made on the basis of the patient's history together with the physician's observations of the patient's overall mood and conversation patterns. People with BDD often come across to others as generally anxious and worried. In addition, the patient's dress or clothing styles may suggest a diagnosis of BDD. It is not unusual, however, for patients with BDD to take offense if their primary care doctor suggests referral to a psychiatrist.
Some physicians may use a self-report question-naire, such as the Multidimensional Body-Self Relations Questionnaire (MBSRQ) or the short form of the Situational Inventory of Body-Image Dysphoria (SIBID), to evaluate patients during an office visit.
There are no brain imaging studies or laboratory tests as of the early 2000s that can be used to diagnose BDD.

Treatment

The standard course of treatment for body dysmorphic disorder is a combination of medications and psychotherapy. Surgical, dental, or dermatologic treatments have been found to be ineffective.
The medications most frequently prescribed for patients with BDD are the selective serotonin reuptake inhibitors, most commonly fluoxetine (Prozac) or sertraline (Zoloft). Other SSRIs that have been used with this group of patients include fluvoxamine (Luvox) and paroxetine (Paxil). In fact, it is the relatively high rate of positive responses to SSRIs among BDD patients that led to the hypothesis that the disorder has a neurobiological component related to serotonin levels in the body. An associated finding is that patients with BDD require higher dosages of SSRI medications than patients who are being treated for depression with these drugs.
The most effective approach to psychotherapy with BDD patients is cognitive-behavioral restructuring. Since the disorder is related to delusions about one's appearance, cognitive-oriented therapy that challenges inaccurate self-perceptions is more effective than purely supportive approaches. Thought-stopping and relaxation techniques also work well with BDD patients when they are combined with cognitive restructuring.
Some doctors recommend couples therapy or family therapy in order to involve the patient s parents, spouse, or partner in his or her treatment. This approach may be particularly helpful if family members are critical of the patient s looks or are reinforcing his or her unrealistic body image.

Alternative treatment

Although no alternative or complementary form of treatment has been recommended specifically for BDD, such herbal remedies for depression as St. John's wort have been reported as helping some BDD patients. Aromatherapy appears to be a useful aid to relaxation techniques as well as a pleasurable physical experience for BDD patients. Yoga has helped some persons with BDD acquire more realistic perceptions of their bodies and to replace obsessions about external appearance with new respect for their body's inner structure and functioning.

Prognosis

As of early 2005, the prognosis of BDD is considered good for patients receiving appropriate treatment. On the other hand, researchers do not know enough about the lifetime course of body dysmorphic disorder to offer detailed statistics. DSM-IV-TR notes that the disorder "has a fairly continuous course, with few symptom-free intervals, although the intensity of symptoms may wax and wane over time."

Prevention

Given the pervasive influence of the mass media in contemporary Western societies, the best preventive strategy involves challenging their unrealistic images of attractive people. Parents, teachers, primary health care professionals, and other adults who work with young people can point out and discuss the pitfalls of trying to look "perfect." In addition, parents or other adults can educate themselves about BDD and its symptoms, and pay attention to any warning signs in their children's dress or behavior.

Resources

Books

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision. Washington, DC: American Psychiatric Association, 2000.
"Body Dysmorphic Disorder," Section 15, Chapter 186 in The Merck Manual of Diagnosis and Therapy, edited by Mark H. Beers, MD, and Robert Berkow, MD. Whitehouse Station, NJ: Merck Research Laboratories, 2004.
Johnston, Joni E., Psy D. Appearance Obsession: Learning to Love the Way You Look. Deerfield Beach, FL: Health Communications, Inc., 1994.
Rodin, Judith, PhD. Body Traps: Breaking the Binds That Keep You from Feeling Good About Your Body. New York: William Morrow, 1992.

Periodicals

Arthur, Gary K., MD, and Kim Monnell, DO. "Body Dysmorphic Disorder." eMedicine, 3 September 2004. http://www.emedicine.com/med/topic3124.htm.
Cafri, G., J. K. Thompson, L. Ricciardelli, et al. "Pursuit of the Muscular Ideal: Physical and Psychological Consequences and Putative Risk Factors." Clinical Psychology Review 25 (February 2005): 215-239.
Kirchner, Jeffrey T. "Treatment of Patients with Body Dysmorphic Disorder." American Family Physician 61 (March 2000): 1837-1843.
Slaughter, James R. "In Pursuit of Perfection: A Primary Care Physician's Guide to Body Dysmorphic Disorder." American Family Physician 60 (October 1999): 569-580.

Organizations

American Academy of Child and Adolescent Psychiatry. 3615 Wisconsin Avenue, NW, Washington, DC 20016-3007. (202) 966-7300. Fax: (202) 966-2891. www.aacap.org.
American Psychiatric Association (APA). 1000 Wilson Boulevard, Suite 1825, Arlington, VA 22209-3901. (800) 368-5777 or (703) 907-7322. Fax: (703) 907-1091. http://www.psych.org.

body

 [bod´e]
trunk (def. 1).
1. the largest and most important part of any organ.
2. any mass or collection of material.
acetone b's ketone bodies.
alkapton b's a class of substances with an affinity for alkali, found in the urine and causing the condition known as alkaptonuria. The compound commonly found, and most commonly referred to by the term, is homogentisic acid.
amygdaloid body a small mass of subcortical gray matter within the tip of the temporal lobe, anterior to the inferior horn of the lateral ventricle of the brain. It is part of the limbic system.
aortic b's small neurovascular structures on either side of the aorta in the region of the aortic arch, containing chemoreceptors that play a role in reflex regulation of respiration.
asbestos b's golden yellow bodies of various shapes, formed by the deposition of calcium salts, iron salts, and proteins on a spicule of asbestos, found in the lungs, lung secretions, and feces of patients with asbestosis.
Aschoff b's submiliary collections of cells and leukocytes in the interstitial tissues of the heart in the myocarditis that accompanies rheumatic fever; called also Aschoff's nodules.
asteroid body an irregularly star-shaped inclusion body found in the giant cells in sarcoidosis and other diseases.
Babès-Ernst body metachromatic granule.
Barr body sex chromatin.
basal body a modified centriole that occurs at the base of a flagellum or cilium.
carotid b's small neurovascular structures lying in the bifurcation of the right and left carotid arteries, containing chemoreceptors that monitor the oxygen content of the blood and help to regulate respiration.
ciliary body see ciliary body.
Donovan b's encapsulated bacteria (Calymmatobacterium granulomatis) found in lesions of granuloma inguinale, visible when a Wright-stained smear of infected tissue is viewed under a microscope.
body dysmorphic disorder a somatoform disorder in which a normal-appearing person is either preoccupied with an imagined defect in appearance or is overly concerned about a very slight physical anomaly. See also body image. Called also dysmorphophobia.
fimbriate body corpus fimbriatum.
foreign body a mass of material that is not normal to the place where it is found.
fruiting body a specialized structure of certain fungi that produces the spores.
geniculate body, lateral either of the two metathalamus eminences, one on each side just lateral to the medial geniculate bodies, marking the termination of the optic tract.
geniculate body, medial either of the two metathalamus eminences, one on each side just lateral to the superior colliculi, concerned with hearing.
hematoxylin body a dense, homogeneous particle, easily stainable with hematoxylin, consisting of nuclear material derived from an injured cell together with a small amount of cytoplasm. Hematoxylin bodies occur in systemic lupus erythematosus. Lymphocytes that ingest such particles are known as le cells. Called also LE body.
Howell's b's (Howell-Jolly b's) smooth, round remnants of nuclear chromatin seen in erythrocytes in megaloblastic and hemolytic anemia, in various leukemias and after splenectomy.
body image the total concept, including conscious and unconscious feelings, thoughts, and perceptions, that a person has of his or her own body as an object in space independent and apart from other objects. The body image develops during infancy and childhood from exploration of the body surface and orifices, from development of physical abilities, and from play and comparison of the self with others. Changes in body image are particularly important in adolescence when attention is focused on appearance and attractiveness and relations with others. Body image is strongly influenced by parental attitudes that give the child a perception of certain body parts as good, clean, and attractive, or bad, dirty, and repulsive. The evolution of body image continues throughout life and incorporates such factors as a person's style of dress, hair style, and use of makeup, which symbolize social and professional status and other feelings about the self.

Many clinical syndromes involve disturbances of body image. Disturbed body image is a nursing diagnosis that was approved by the North American Nursing Diagnosis Association, defined as confusion in the mental picture of one's physical self. Surgery or trauma involving disfigurement or loss of a body part can be very threatening to a patient. Diseases involving a loss of body function, such as stroke syndrome, paraplegia, quadriplegia, coronary heart disease, and bowel or bladder incontinence, and diseases involving disfiguring skin lesions or the feeling of “rotting away” as in cancer or gangrene, can all cause changes in body image. Body image is frequently disturbed in schizophrenia, and patients may feel that their body or its parts are changing in size or shape or are ugly or threatening. Rape or violent physical assault can disturb the feeling of being secure in one's own body. Changes in body image involving sexual attractiveness or sexual identity, such as surgery or trauma involving the genitals or breasts and tubal ligation, hysterectomy, or vasectomy, can be especially difficult for the patient to deal with. Intrusive therapeutic or diagnostic procedures, such as insertion of a nasogastric tube, bladder catheterization, administration of intravenous fluids, endoscopy, and cardiac catheterization, can also threaten a patient's body image.

The reaction of a patient to an alteration in body image can include mourning the loss of the former body image, fear of rejection by significant others, hostility, and experiencing of “phantom” sensations from missing body parts. Patients with less ability to cope with their loss may respond with denial or depression. This can lead to a rejection of the altered body image and feelings of depersonalization that can involve avoidance of interpersonal contact and an unwillingness to discuss the deformity or to accept corrective medical treatment or vocational rehabilitation.
inclusion b's round, oval, or irregular-shaped bodies in the cytoplasm and nuclei of cells, as in disease caused by viral infection, such as rabies, smallpox, and herpes.
ketone b's see ketone bodies.
lamellar body keratinosome.
Lafora's b's intracytoplasmic inclusions consisting of a complex of glycoprotein and acid mucopolysaccharide; widespread deposits are found in Lafora's disease, a type of epilepsy.
Leishman-Donovan b's round or oval bodies found in the reticuloendothelial cells, especially those of the spleen and liver, in kala-azar; they are nonflagellate intracellular forms of Leishmania donovani. Also used to designate similar forms of Leishmania tropica found in macrophages in lesions of cutaneous leishmaniasis.
mamillary body (mammillary body) either of the pair of small spherical masses in the interpeduncular fossa of the midbrain, forming part of the hypothalamus.
Masson b's cellular tissue that fills the pulmonary alveoli and alveolar ducts in rheumatic pneumonia; they may be modified Aschoff's bodies.
molluscum b's large homogeneous intracytoplasmic inclusions found in the stratum granulosum and stratum corneum in molluscum contagiosum, which contain replicating virus particles and cellular debris.
multilamellar body any of the osmiophilic, lipid-rich, layered bodies found in the great alveolar cells of the lung.
Negri b's oval or round bodies in the nerve cells of animals dead of rabies.
Nissl b's large granular bodies that stain with basic dyes, forming the reticular substance of the cytoplasm of neurons, composed of rough endoplasmic reticulum and free polyribosomes; ribonucleoprotein is one of their main constituents. Called also Nissl's granules.
olivary body olive (def. 2).
paraaortic b's see para-aortic bodies.
pineal body see pineal body.
pituitary body pituitary gland.
polar b's
1. the small cells consisting of a tiny bit of cytoplasm and a nucleus; they result from unequal division of the primary oocyte (first polar body) and, if fertilization occurs, of the secondary oocyte (second polar body).
2. metachromatic granules located at one or both ends of a bacterial cell.
psammoma b's usually microscopic, laminated masses of calcareous material, occurring in both benign and malignant epithelial and connective-tissue tumors, and sometimes associated with chronic inflammation.
quadrigeminal b's corpora quadrigemina.
body of sternum the second or main part of the sternum, bounded by the manubrium above and the xiphoid process below. Called also gladiolus and corpus sterni.
striate body corpus striatum.
trachoma b's inclusion bodies found in clusters in the cytoplasm of the epithelial cells of the conjunctiva in trachoma.
vitreous body the transparent gel filling the inner portion of the eyeball between the lens and retina. Called also vitreous and vitreous humor.
wolffian body mesonephros.

bod·y dys·mor·phic dis·or·der

1. a psychosomatic (somatoform) disorder characterized by preoccupation with some imagined defect in appearance in a person who looks normal.
2. a DSM diagnosis that is established when the specified criteria are met.
Synonym(s): dysmorphophobia

body dysmorphic disorder

n.
A psychiatric disorder characterized by chronic and obsessive preoccupation with perceived defects in one's physical appearance that appear minor or are not visible to others and that are not related to fat or body weight.
A psychiatric condition in which the patient has a profound negative distortion of his/her body image, which may hinge on perceived craniofacial flaws or imperfections of physique, leading to compulsive checking of his/her appearance in the mirror, intense self-consciousness, social avoidance, isolation and depression

body dysmorphic disorder

Beauty hypochondria, dysmorphophobia Psychiatry A psychiatric condition in which the Pt has a profound negative distortion of his or her body image, which may hinge on a perceived craniofacial flaw; Pts with BDD have obsessive body-image concerns, leading to compulsive checking of appearance in the mirror, intense self-consciousness, social avoidance and isolation, and depression. See Body image. Cf Anorexia nervosa.

bod·y dys·mor·phic dis·or·der

(bod'ē dis-mōr'fik dis-ōr'dĕr)
1. A psychosomatic (somatoform) disorder characterized by preoccupation with some imagined defect in appearance in a person who looks normal.
2. A DSM diagnosis that is established when the specified criteria are met.
Synonym(s): dysmorphophobia.

bod·y dys·mor·phic dis·or·der

(bod'ē dis-mōr'fik dis-ōr'dĕr)
Psychosomatic disorder characterized by preoccupation with some imagined defect in appearance.