Body dysmorphic disorder

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.^[1] In BDD's delusional variant, the flaw is imagined.^[2] If the flaw is actual, its importance is severely exaggerated.^[2] 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.

A fairly common mental disorder, estimated to affect up to 2.4% of the population, BDD usually starts during adolescence, and affects men and women roughly equally.^[2][3] (The BDD subtype muscle dysmorphia, perceiving the body as too small, affects mostly males.)^[4] Besides thinking about it, one repetitively checks and compares the perceived flaw, and can adopt unusual routines to avoid social contact that exposes it.^[2] Fearing the stigma of vanity, one usually hides the preoccupation.^[2] Commonly unsuspected even by psychiatrists, BDD has been greatly underdiagnosed.^[2] Severely impairing quality of life via educational and occupational dysfunction and social isolation, BDD involves especially high rates of suicidal ideation and suicide attempts.^[2]

Signs and symptoms

Whereas vanity concerns preoccupation with aggrandizing the appearance, BDD is compulsion to merely normalize the appearance.^[2] Although delusional in about one of three cases, the appearance concern is usually an overvalued idea.^[3] The perceived bodily defect can be at virtually any area, yet is usually the nose, stomach, thighs, skin, or hair.^[2] Cognitive testing and neuroimaging suggest both a bias toward detailed visual analysis and a tendency toward emotional hyperarousal.^[5]

Via BDD, some persons experience delusions that others are covertly pointing out their flaws.^[2] BDD can prompt a quest for dermatological treatment or cosmetic surgery, which interventions typically do not resolve the distress.^[2] On the other hand, attempts at self-treatment can paradoxically create lesions where none previously existed.^[2] BDD shares features with obsessive-compulsive disorder,^[6] but involves more depression and social avoidance.^[1] BDD often associates with social anxiety disorder.^[7]

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.^[1][2] 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.^[2] 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.^[2]

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.^[8][9] Though twin studies into BDD are few, one estimated its heritability at 43%,^[10] although BDD's causation may involve introversion,^[11] negative body image, perfectionism,^[8][12] heightened aesthetic sensitivity,^[9] and childhood abuse and neglect.^[9][13]

Diagnosis

Estimates of prevalence and gender distribution have varied widely via discrepancies in diagnosis and reporting.^[1] In American psychiatry, BDD gained diagnostic criteria in the DSM-IV, but clinicians' knowledge of it, especially among general practitioners, is constricted.^[14] Meanwhile, the shame that persons feel about having the bodily concern, and fearing the stigma of vanity, hinders recognition.^[2][15] BDD is sometimes mistaken for major depressive disorder or social phobia.^[16] BDD is severely under-diagnosed even in psychiatric patients.^[17] Correct diagnosis calls for specialized questioning and correlation with emotional distress or social dysfunction.^[17] Estimates place the Body Dysmorphic Disorder Questionnaire's sensitivity at 100% (0% false negatives) and specificity at 92.5% (7.5% false positives).^[18]

Treatment

BDD's delusional variant does not respond to treatment with antipsychotic drugs, but instead with some antidepressant drugs, the selective serotonin reuptake inhibitors (SSRIs).^[2] Believed to be more effective,^[3] the primary intervention for BDD is cognitive-behavioral therapy (CBT).^[19][20][21] CBT for BDD mainly involves exposure (entering a distressful situation) and response prevention (avoiding the dysfunctional reaction).

History

In 1886, Enrico Morselli reported a disorder that he termed dysmorphophobia.^[22] 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).^[3] Classifying it as a distinct somatoform disorder, the DSM-III's 1987 revision switched the term to body dysmorphic disorder.^[3]

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.^[3][23] 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).

Notes

External links

• Looks that Kill, TV documentary by a recovered person with BDD, John Furse
• International Obsessive Compulsive Disorder Foundation BDD website