Body Dysmorphic Disorder

12.1 Definition

Body dysmorphic disorder (BDD) is defined as a preoccupation with an imagined or a very slight defect in physical appearance that causes significant distress to the individual. It was first described by Morselli in 1886 [1] who called it “dysmorphophobia.” The disorder is manifested in people who dislike some aspect of how they look to such an extent that they cannot stop thinking and worrying about it. To other people these reactions may seem excessive as the supposed problem may not even be noticeable or is related to a very minor blemish such as a mole, or mild acne scarring that anyone else may not even notice. To sufferers of the syndrome the “defects” are very real, very obvious, and very severe.

12.2 Symptoms

1.There is preoccupation with the supposed appearance problem.

2.The patient takes actions to “hide” the defect or avoid situations because they feel ugly and do not want to be seen by others.

Some patients with body dysmorphia realize they look worse to themselves than to others and that their view of their appearance is exaggerated and distorted. Others

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are convinced that their view of their physical defect is accurate. Some have the feeling that other people are taking special notice of the “defect,” that people are staring at it and making fun of it or laughing about it behind their backs when in reality, no one may even notice it. Many sufferers feel ashamed and fear being rejected by others.

Most patients with BDD perform one or more repetitive and often time-consuming behaviors also known as “rituals” that are usually aimed at examining, “improving,” or hiding the perceived flaw in appearance. They usually spend a lot of time checking in the mirror to see whether their “defect” is noticeable or has changed in some way. Others will frequently compare themselves with other people or images in magazines or billboards. Some will spend hours “grooming” themselves by applying makeup, changing clothes, or rearranging their hair to “correct” or cover up the “problem.” Others attempt to camouflage or hide their defect by wearing a hat, a wig, or sunglasses. In extreme cases, people wear a mask or hood over their head. Some try, by acting or standing in a certain way in public, to make the defect seem less noticeable. Others weigh or measure themselves continually or wear big and baggy clothing to hide what they think are “huge” hips or large breasts. Some may wear many layers of clothing to make themselves appear larger or more muscular, and some men (especially those who suffer from “muscle dysmorphia”) lift weights or exercise excessively to try to bulk up. They may eat special diets or use drugs such as anabolic steroids to try to build up their muscles.

Patients with body dysmorphia may approach cosmetic surgeons or dermatologists seeking surgery or medical treatments that place the doctor at risk for a continually dissatisfied patient with whatever is done.

12.3 Consequences of BDD

Some patients with BDD function well despite their distress. Others are severely impaired by their symptoms, often becoming socially isolated by not going to school or work and extreme cases refusing to leave home for fear of being embarrassed about their appearance. It can be especially difficult for sufferers to go to places such as beaches, hairdressers, shopping, or places where the person may feel anxious about how they look. It is not uncommon for patients with BDD to feel depressed about their problem and the negative impact this has on their life. Some become so desperate that they attempt suicide.

Relationship problems are common and many BDD sufferers have few friends, avoiding dates and other social activities or even getting divorced because of their symptoms.

12.4 Associated Disorders

Many patients with BDD also suffer from depression at some point in their life and there is a high rate of depression in families of patients who develop BDD. The patient develops low esteem, feelings of rejection, heightened sensitivity, and of being unworthy.

Other disorders include obsessive compulsive disorder (OCD) such as eating disorders, anxiety disorders, trichotillomania (hair pulling), and abuse of drugs or alcohol.

There is a high rate of suicidal ideation (mean 57.8% of 185 subjects over 4 years) and a mean of 2.6% attempted suicide per year [2, 3].

12.5 Treatment

Serotonin-reuptake inhibitors (SRIs) are a group of medications that appear to be useful and effective in patients with BDS. The SRIs are a type of antidepressant used successfully in the treatment of both depression and obsessive compulsive disorder. These include Prozac, Zoloft, Cipramil, and Aropax.

Cognitive behavioral therapy (CBT) appears to be an effective treatment for BDD [4]. The behavioral component consists of “Exposure and Response

Prevention” where the patient exposes their defect in situations which they would usually avoid while response prevention involves helping the patient stop carrying out the compulsive behavior related to the defect. The aim over time is to decrease anxiety involved with that particular avoided situation. The cognitive component addresses the range of intrusive thoughts that accompany the behaviors, or rituals such as mirror checking, in BDS. This focuses on exploring beliefs and values that support and strengthen a person’s perceptions about their body. Cognitive restructuring is aimed at developing an understanding of how these strongly held values impact the person’s sense of “self” and to progressively build up alternative ways of thinking about the intrusive thought, rather than going through the usual range of behaviors such as mirror checking and reassurance seeking. Restructuring consists of a range of techniques involving making changes to a person’s values while not directly questioning the repetitive and intrusive thought the person has about their body.

12.6 Discussion

Understanding BDD and recognizing the patient with this disorder will prevent many misunderstandings between patient and doctor, especially the dermatologist or cosmetic surgeon. The BDD patient presenting for treatment of minimally abnormal skin findings, if recognized, will prevent unnecessary and potentially unsuccessful treatments [5-7]. Many patients with BDD seek cosmetic surgery and the unwary surgeon will invariably have to deal with a dissatisfied patient. Many eventually fall into the cosmetic surgery victim category of “overoperation.” Recognition and deferral of surgery for BDD patients is advised because findings have shown the propensity of these patients to litigate, threaten, and even harm or kill their surgeon [8].

12.7 Conclusions

Failure to diagnose BDD in a preoperative cosmetic surgery patient will almost always lead to a dissatisfied patient. The surgeon will have a patient who is continuously dissatisfied with results no matter what is

done to correct the perceived deformity. The treatment for the patient with BDD is medications, usually SRIs, or psychiatric care with cognitive behavioral therapy. The surgeon has to identify the BDD patients before surgery and tell them that surgery is not the treatment for their problem and refer them to the psychiatrist for treatment.

References

1.Thomas I, Patterson WM, Szepietowski JC, Chodynicki MP, Janniger CK, Hendel PM, et al. Body dysmorphic disorder: more than meets the eye. Acta Dermatovenerol Croat. 2005; 13(1):50–3.

2.Phillips KA, Menard W. Suicidality in body dysmorphic disorder: a prospective study. Am J Psychiatry. 2006;163(7): 1280–2.

3.Phillips KA, Coles ME, Menard W, Yen S, Fay C, Weisberg RB. Suicidal ideation and suicide attempts in body dysmorphic disorder. J Clin Psychiatry. 2005;66(6): 717–25.

4.Honigman R, Castle DJ. Body dysmorphic disorder – a guide for people with BDD. Victoria: Collaborative Therapy Unit, Mental Health Research Institute; 2003.

5.Buescher LS, Buescher KL. Body dysmorphic disorder. Dermatol Clin. 2006;24(2):251–7.

6.Glaser DA, Kaminer MS. Body dysmorphic disorder and the liposuction patient. Dermatol Surg. 2005;31(5):559–60.

7.Mackley CL. Body dysmorphic disorder. Dermatol Surg. 2005;31(5):553–8.

8.Hodgkinson DJ. Identifying the body-dysmorphic patient in aesthetic surgery. Aesthetic Plast Surg. 2005;29(6):503–9.