Body Dysmorphic Disorder

BASICS

DESCRIPTION

Body dysmorphic disorder (BDD) is a somatoform disorder in which patients have pervasive subjective feelings of ugliness about one or more aspects of their appearance despite a normal or near-normal appearance.

Diagnostic criteria according to the DSM-5 are as follows (all must be met for diagnosis) (1):
- Preoccupation with a perceived defect in appearance. If there is a minor physical anomaly present, the concern is excessive.
- At some point, the individual has performed repetitive behaviors or mental acts in response to the appearance concerns.
- The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of function.
- The preoccupation is not accounted for by another mental disorder or meets criteria for an eating disorder.
Specifiers
- With muscle dysmorphia, when the patient is preoccupied with the idea that his or her body build is too small or insufficiently muscular.
- By degree of insight regarding BDD beliefs:
  - With good or fair insight: The individual recognizes that the BDD beliefs are definitely or probably not true or that they may or may not be true.
  - With poor insight: The individual thinks that the BDD beliefs are probably true.
  - With absent insight/delusional beliefs: The individual is completely convinced that the BDD beliefs are true.

EPIDEMIOLOGY

Usually begins during adolescence, mean age of onset 16.7 years. Onset is rare after age 40 (2).
Women are affected more often than men, except for muscle dysmorphia, which occurs almost exclusively in males.
Different cultural beliefs may influence or amplify preoccupations:
- Adolescents usually present similar to adults.
- Can be present in childhood, often with refusing to attend school or planning suicide
Onset is usually gradual but can be abrupt.
Often, a delay in diagnosis until 10 to 15 years after the onset of symptoms

Prevalence

Point prevalence 1.7-2.4% (3,4)
Slightly more common in United States (1)
More common in women (2.4%) than men (2.2%)
Muscle dysphoria is much more common in men.
More common in individuals with anxiety, depressive disorders, or obsessive-compulsive disorder (OCD)
6-15% in cosmetic surgery patients and in dermatologic clinics

ETIOLOGY AND PATHOPHYSIOLOGY

Not well understood, but likely multifactorial involving genetic, biologic, and environmental factors
A cognitive-behavioral model describes reinforcement-based operant conditioning and social learning pertaining to attractiveness that leads to development of maladaptive appearance-related behaviors, beliefs, and values, especially traits of perfectionism. Attractiveness is very important to them, but they feel unattractive and this leads to poor self-esteem (5).
Functional MRI studies of patients with BDD note abnormalities in visual processing and frontostriatal systems, specifically left cerebral hemisphere hyperactivity. This may lead to selective recall of details and perception of distortions that do not exist (6).

RISK FACTORS

Genetic predisposition-estimated heritability of 43%; appears to be clustered with OCD and hoarding disorder (7).
Anxiety disorder or social phobia (8)
Pathologic skin picking (8)
Shyness, perfectionism, or anxious temperament
Childhood adversity
- Childhood abuse or neglect
- Teasing or bullying
- Poor peer relationships
- Social isolation
History of dermatologic or other physical stigmata
Being more aesthetically sensitive than average
Low self-esteem

COMMONLY ASSOCIATED CONDITIONS

Major depressive disorder (46%, most common) (9)
Social anxiety disorder (35%)
Panic attacks (29%) (4)
OCD (17%)
Substance-related disorders
Bipolar disorder
Eating disorders
Attempted suicide
Delusional disorder

DIAGNOSIS

HISTORY

Determine the patient's concern.
Determine the severity of the disorder.
Quantify the amount of time spent worrying about the "distorted" appearance.
Determine what is to be done to hide or eliminate the problem.
Determine the degree to which the defect affects school, job, or social life.
Assess other psychiatric disorders and history of psychiatric disorders.
Signs and symptoms may include the following:
- Preoccupation that one or more features are unattractive, ugly, or deformed
- Can involve any part of the body but usually involves the skin, hair, or facial features.
  - Women are more likely to be preoccupied with their weight, hips, legs, and breasts.
  - Men are more likely to be preoccupied with their height, body hair, body build, and genitals.
Nature of the preoccupation can change with time.
Patients typically have poor insight.
Patient tends to display delusions of reference.
Often present initially to dermatologists (8).
Much time is consumed by behaviors to examine the perceived defect repeatedly, disguise it, or improve it:
- Mirror gazing
- Excessive grooming
- Camouflaging the "defect"
- Skin picking
- Reassurance seeking
- Dieting
Tendency to avoid social interactions
Trouble staying in school, maintaining a job, or maintaining significant relationships
- Tends to be unhappy with results of dermatologic and cosmetic procedures

PHYSICAL EXAM

Important to do a mental status examination
- Look for the following:
  - Depression
  - Suicidal ideation
  - Anxiety
  - OCD
Rule out organic factors by reviewing the following:
- Orientation
- Memory
- Ability to concentrate
Rule out actual physical pathology.

DIFFERENTIAL DIAGNOSIS

Normal concerns about appearance or normal reaction to physical defect
Eating disorders: In eating disorders, concerns of body weight are secondary to the eating disorder. In BDD the preoccupations are the principal concern. The conditions can also be comorbid.
OCD: In BDD, the obsessions and compulsions are restricted only to appearance, not generalized as in OCD. BDD also tends to have poorer insight than patients with OCD.
Major depressive episode or MDD
Narcissistic personality disorder
Avoidant personality disorder
Social phobia
Schizophrenia
Trichotillomania
Hypochondriasis
Delusional disorder, somatic type
Koro: a cultural syndrome seen in Southeast Asia that involves a preoccupation that the genitals (penis, labia, nipples, or breast) are shrinking and disappearing into the abdomen. The preoccupation is with the death that will inevitably follow rather than the physical deformity.

DIAGNOSTIC TESTS & INTERPRETATION

Several modules have been developed to assist with the diagnosis and severity rating of BDD (10)[A].
Administered by a trained clinician, these include the following:
- The Body Dysmorphic Disorder Examination
- Yale-Brown Obsessive Compulsive Scale modified for BDD
- BDD section of the Mini International Neuropsychiatric Interview (MINI)-Plus

TREATMENT

In any patient with a coexisting mental disorder, such as a depressive or anxiety disorder, the coexisting disorder should be treated with the appropriate psychotherapy or pharmacotherapy (10,11)[A].
Cognitive-behavioral therapy (CBT) has been shown to be effective in small randomized controlled trials (RCTs) and is currently the standard of care in addition to pharmacotherapy (10, 11, 12, 13)[A].
CBT for BDD typically involves constructing a hierarchy of specific body parts and feared situations, followed by response prevention (ritualistic behaviors) and cognitive restructuring (14).
Other forms of psychotherapy such as group CBT may also be effective (13)[A].

MEDICATION

First Line

SSRIs are currently considered the medication of choice for BDD.
- Not an FDA-approved use
Results from RCTs suggest that SSRIs such as fluvoxamine, citalopram, and fluoxetine may be useful in treating patients with BDD (12,15,16)[A].
Maximum tolerated dose should be taken for at least 12 to 16 weeks (12,15)[A].

Second Line
Antipsychotics, lithium, or methylphenidate adjunctive therapy with an SSRI may be effective, especially in those with BDD and delusional beliefs (10,16)[A].

ISSUES FOR REFERRAL

Referral to a psychiatrist for diagnosis and therapy can be helpful and necessary for difficult cases.
Regular counseling

SURGERY/OTHER PROCEDURES

Retrospective reports suggest that persons with BDD rarely experience resolution of their symptoms following these treatments, leading some to suggest that BDD is a contraindication to cosmetic surgery and other treatments (17)[C].

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

Patient Monitoring
Many patients have substantial improvement in core BDD symptoms, psychosocial functioning, quality of life, suicidality, and other aspects of BDD when treated with appropriate psychopharmacotherapy that targets BDD symptoms.

PATIENT EDUCATION

Phillips KA. Broken Mirror: Understanding and Treating Body Dysmorphic Disorder. Rev and expanded ed. New York, NY: Oxford University Press; 2005.
Butler Hospital Body Dysmorphic Disorder and Body Image Program at http://www.rhodeislandhospital.org/psychiatry/body-image-program.html

PROGNOSIS

Continuous course with periods of waxing and waning in the intensity of symptoms
Lower likelihood of full or partial remission if more severe BDD symptoms at onset, longer lifetime course of BDD, or as an adult (4)
If early onset (before 18 years old), increased likelihood of attempted suicide and other psychiatric comorbidities (2)
Often experience increased distress and impaired interpersonal functioning (9)

COMPLICATIONS

Repeated surgical or dermatologic procedures
Inability or limited ability to function in society
Poor social relations
Poor self-esteem
Suicide

REFERENCES

11 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Association; 2013.22 Bjornsson AS, Didie ER, Grant JE, et al. Age at onset and clinical correlates in body dysmorphic disorder. Compr Psychiatry. 2013;54(7):893-903.33 Phillips KA, Menard W, Bjornsson AS. Cued panic attacks in body dysmorphic disorder. J Psychiatr Pract. 2013;19(3):194-203.44 Phillips KA, Menard W, Quinn E, et al. A 4-year prospective observational follow-up study of course and predictors of course in body dysmorphic disorder. Psychol Med. 2013;43(5):1109-1117.55 Feusner JD, Neziroglu F, Wilhelm S, et al. What causes BDD: research findings and a proposed model. Psychiatr Ann. 2010;40(7):349-355.66 Feusner JD, Moody T, Hembacher E, et al. Abnormalities of visual processing and frontostriatal systems in body dysmorphic disorder. Arch Gen Psychiatry. 2010;67(2):197-205.77 Monzani B, Rijsdijk F, Harris J, et al. The structure of genetic and environmental risk factors for dimensional representations of DSM-5 obsessive-compulsive spectrum disorders. JAMA Psychiatry 2014;71(2):182-189.88 Mufaddel A, Osman OT, Almugaddam F, et al. A review of body dysmorphic disorder and its presentation in different clinical settings. Prim Care Companion CNS Disord. 2013;15(4):PCC. 12r01464.99 van der Meer J, van Rood YR, van der Wee NJ, et al. Prevalence, demographic and clinical characteristics of body dysmorphic disorder among psychiatric outpatients with mood, anxiety or somatoform disorders. Nord J Psychiatry. 2012;66(4):232-238.1010 Ipser JC, Sander C, Stein DJ. Pharmacotherapy and psychotherapy for body dysmorphic disorder. Cochrane Database Syst Rev. 2009;(1):CD005332.1111 Williams J, Hadjistavropoulos T, Sharpe D. A meta-analysis of psychological and pharmacological treatments for body dysmorphic disorder. Behav Res Ther. 2006;44(1):99-111.1212 Somashekar B, Jainer A, Wuntakal B. Psychopharmacotherapy of somatic symptoms disorders. Int Rev Psychiatry. 2013;25(1):107-115.1313 Prazeres AM, Nascimento AL, Fontenelle LF. Cognitive-behavioral therapy for body dysmorphic disorder: a review of its efficacy. Neuropsychiatr Dis Treat. 2013;9:307-316.1414 Lewin AB, Wu MS, McGuire JF, et al. Cognitive behavior therapy for obsessive-compulsive and related disorders. Psychiatr Clin North Am. 2014;37(3):415-445.1515 Buhlmann U, Winter A. Perceived ugliness: an update on treatment-relevant aspects of body dysmorphic disorder. Curr Psychiatry Rep. 2011;13(4):283-288.1616 Phillips KA, Hollander E. Treating body dysmorphic disorder with medication: evidence, misconceptions, and a suggested approach. Body Image. 2008;5(1):13-27.1717 Shridharani SM, Magarakis M, Manson PN, et al. Psychology of plastic and reconstructive surgery: a systematic clinical review. Plast Reconstr Surg. 2010;126(6):2243-2251.

CODES

ICD10

F45.22 Body dysmorphic disorder

ICD9

300.7 Hypochondriasis

SNOMED

body dysmorphic disorder (disorder)

CLINICAL PEARLS

BDD is characterized by the patient's preoccupation with a perceived defect in appearance of at least one body part or area.
At some point during the course of the disorder, the individual has performed repetitive behaviors or mental acts in response to the appearance concerns.
The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of function.
Coexisting mental disorders should be diagnosed and treated.
Cognitive behavior therapy and SSRIs are the mainstays of treatment.
Consider BDD as a diagnosis in patients seeking repeated cosmetic surgeries or other appearance-enhancing treatments.

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