Body Dysmorphic Disorder (BDD) - In Search Of Perfection
Margaret E. Woltjer, Ph.D. | December 2005

Overview
Body Dysmorphic Disorder (BDD) is a serious illness in which the individual is excessively preoccupied with a perceived imperfection that often results in significant distress or impaired functioning. A person with BDD focuses on a minor or imaginary physical flaw that others may not notice. Because BDD is characterized by physical symptoms that are suggestive of a medical condition, many clinicians believe it is a type of somatoform disorder. Others feel it is a variant of Obsessive-Compulsive Disorder (OCD) or an anxiety disorder since BDD frequently co-exists with one or both of these disorders. Although there are similarities with these disorders, there are also distinctive features. According to the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV), the criteria for BDD are:
  • Preoccupation with an imagined defect in appearance. If a slight physical anomaly is present, the person’s concern is markedly excessive.
  • The preoccupation causes clinically significant distress or impairment in social, occupational or other important areas of functioning.
  • The preoccupation is not better accounted for by another mental disorder (e.g., dissatisfaction with overall body shape and size in anorexia nervosa).
Common Signs and Symptoms
Typical signs and symptoms of body dysmorphic disorder include:
  • Frequently comparing the appearance of the perceived flaw with that of others
  • Frequently checking the appearance of the specific body part in mirrors or other reflective surfaces
  • Avoiding mirrors
  • Wearing baggy clothing to mask the “flaw”; trying to camouflage the “defect” through use of makeup, hats, hands, or posture
  • Frequently touching or picking at the area of concern
  • Measuring the disliked body part
  • Excessive attention to grooming
  • Seeking reassurance about the “flaw” or trying to convince others that it is abnormal or excessive
  • Excessively reading about the defective body part
  • Refusing to have pictures taken
  • Avoiding social situations in which the “flawed” area may be noticed
  • Feeling anxious or concerned around others
  • Seeking surgery or other medical treatment despite personal opinions of others and recommendations of doctors that the flaw is minimal or doesn’t exist such that treatment is unnecessary
The most common perceived flaws include shape and/or asymmetry of facial features such as shape of the nose, scars, spots, acne, or other blemishes; too much or too little hair; breast size; size or shape of body parts such as mouth, eyes, hips, buttocks, genitalia, etc.). Some individuals are so ashamed that they may drop out of school, quit jobs, or avoid leaving their house altogether.

Associated Features and Complications
As mentioned above, BDD is frequently associated with social isolation. Because this illness can take a heavy toll on family and friends, the affected individual may experience deep guilt and shame. Chronic BDD often includes depression which, if left untreated, can lead to a downward spiral of disability, dependency and suicide (1). One study of 100 patients with BDD reported that nearly one half had been hospitalized for a psychiatric condition, and 30 percent had made at least one suicide attempt (2).

Because persons with BDD are so uncomfortable with their perceived imperfections, a high percentage seek help from their primary physician, or they go directly to a cosmetic surgeon. In one British study, 62 percent of patients with BDD had discussed their symptoms with their primary care physician(3). Of these individuals, 48% had seen a plastic surgeon or dermatologist at least once and 26% had undergone at least one operation. In is estimated that about 2-7% of persons who have undergone cosmetic surgery have BDD (4).

BDD shares some characteristics with other disorders, sometimes making it difficult to sort out and treat. The OCD Center of Los Angeles reported on a study in which it was found that 24% of individuals with BDD also had OCD.(see www.ocdla.com). Other disorders frequently seen with BDD include: Major depression, avoidant personality disorder, social phobia, delusional disorder (somatic type), anorexia nervosa, and gender identity disorder. Because these disorders share common traits with BDD yet are significantly different from BDD and each other in other respects, careful evaluation must be done to discern whether or not more than one diagnosis is present. Complicating this task even further is the possibility that the individual having BDD may trivialize their symptoms due to their shame over them, or they may exaggerate them due to the distorted perceptions usually seen with this illness.

Who tends to get it?
The actual cause of BDD is unclear, although experts believe that contributing factors include biological, psychological and, perhaps, even social or cultural components. BDD seems to affect males and females equally. Very often, signs of BDD begin to appear during the late teen years or in early adulthood, although some signs may be noticeable earlier. Because teenagers especially are preoccupied with acceptance from peers and of how they appear to others, parents may believe this behavior is simply a “phase” the child is going through and that the child will outgrow it.

Support for a biochemical explanation is derived from some evidence that many individuals with BDD come from a family with a history of generalized anxiety disorder or obsessive-compulsive disorder (see www.mayoclinic.com or www.kidshealth.org). Also, because the use of selective serotonin reuptake inhibitors (SSRIs) frequently leads to improvement of symptoms, it is thought that BDD may result from poor regulation and depletion of serotonin (2,5).

Other factors that appear to increase the risk for BDD include families of higher socioeconomic status, those having strict cultural standards, or individuals who feel the need to live up to unobtainable or unrealistically high expectations for personal appearance and success.(See kidshealth.org).

Treatment
Psychotherapy and medication are the primary means of treatment of BDD. Cognitive-behavioral therapy would include education about BDD, challenging thought-distortions, and focusing on helping the individual to gradually learn to face the feared situations and to resist the behavior they feel compelled to perform. Treatment with SSRIs (such as sertaline and fluoxetine) tend to be well-tolerated and can relieve the BDD symptoms sufficiently to improve mood and general functioning. See www.psychnet-uk.com for more information.

An Added Note
Katharine Phillips, MD, the director of the Body Image Program at Butler Hospital in Providence, Rhode Island, has some recommendations about BDD on the web-site www.kidshealth.org. She points out that parents are highly instrumental in helping their child to maintain a positive self-image and self-esteem. This may not only be an important first step in getting the child through a vulnerable phase of life, but it could alert parents to initial signs and symptoms indicative of a major problem. Maintaining an environment that invites the child to discuss his day, her fears and frustrations, and allows for help in problem-solving can assist in early detection and/or prevention of symptoms.

Dr. Phillips adds that being aware of the child’s peer group and what they are influenced by can also be both helpful to the parent and supportive for the child. In a culture where appearance is a major focus, children who are already feeling confused and awkward over the changes they experience in their bodies can benefit from the reassuring words of their parents.

If you already suspect signs of BDD or major depression in your child, contact your physician or a professional therapist for an evaluation.

References
  1. Cotterill JA, Cunliffe WJ. Suicide in dermatological patients. Br J Dermatol 1997;137:246-250.

  2. Phillips KA. Body dysmorphic disorder: Diagnosis and treatment of imagined ugliness. J Clin Psychiztry 1996;57:(suppl 8):61-64.

  3. Veale D, Boocock A, Gournay K, Dryden W, Shah F, Willson R, et al. Body dysmorphic disorder. A survey of fifty cases. Br J Psychiatry 1996; 169:196-201.

  4. Sarwer DB, Wadden TA, Perschuk MJ, Whitaker LA. Body image dissatisfaction and body dysmorphic disorder in 100 cosmetic surgery patients. Plast Reconstr Surg 1998;101:1644-1649.

  5. Phillips KA. Pharmacologic treatment of body dysmorphic disorder. Psychopharmacol Bull 1996;32: 597-605.
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