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Body Dysmorphic Disorder
Introduction
Body dysmorphic disorder (BDD) is a psychiatric condition defined in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition Text Revision (DSM-5-TR) as a preoccupation with a perceived defect or flaw in one’s physical appearance when, in fact, they appear normal. Often underrecognized, BDD is a prevalent psychiatric condition characterized by an all-consuming focus on perceived physical imperfections, leading to distressing repetitive actions and, at times, suicidal behavior and ideation. Individuals with BDD often seek unnecessary surgical interventions.
The DSM has recategorized BDD since its introduction in 1980. Initially described as an atypical somatoform disorder and then a distinct somatoform disorder in 1987, BDD now falls in the DSM-5-TR under the spectrum of obsessive-compulsive and related disorders.[1] Patients affected by BDD have a preoccupation with a perceived defect or flaw in their physical appearance that is either not noticeable or only slightly observable by others. Symptoms cause marked impairment in social, academic, occupational, or other areas of functioning. To meet diagnostic criteria, patients must engage in repetitive behaviors, such as excessive mirror checking, camouflaging (ie, covering up the defect with makeup or clothing), skin picking, excessive grooming, excessive weight lifting, or pervasive mental acts such as comparing one’s appearance to others. These behaviors are time-consuming, difficult to control, and distressing to the individual.[2] Body dysmorphic disorder is underrecognized, and affected patients visit dermatology and plastic surgery clinics to repair their perceived defects. Understanding BDD's features and diagnostic criteria across all healthcare specialties helps increase awareness and recognition of the condition.[3]
In 1891, Enrico Morselli, an Italian psychiatrist, coined the term dysmorphophobia, derived from the Greek word dysmorfia, meaning ugliness, to describe people who perceive themselves as flawed but have no apparent physical deformities. Pierre Janet, a French psychologist, discussed cases of this condition and labeled it "l'obsession de la honte du corps," which translates to "obsessions of shame of the body." Sigmund Freud also detailed a case known as "Wolf Man," a man obsessed with his nose, which caused him significant social distress.
Etiology
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Etiology
Body dysmorphic disorder develops from psychological, social, and biological factors. High-quality studies investigating the pathogenesis of BDD are limited and small. Neuroimaging findings discovered in studies could be etiologic findings or sequelae from the disease process. One preliminary candidate gene study of 57 subjects with BDD matched with 58 healthy controls demonstrated that the GABA-A-gamma-2 (5q31.1-q33.2) receptor gene occurred more frequently in subjects with BDD than in the controls. [4] The heritability of BDD, investigated through twin studies, revealed an estimated 43% genetic contribution for BDD.[5] The remaining contributors are psychological and environmental. A history of physical or sexual abuse may contribute to the development of BDD. [6] Individuals who report lower levels of perceived parental care in childhood or a history of parental neglect have a higher prevalence of BDD than controls. [7]
Epidemiology
BDD is reported globally in all ages, in both males and females. The overall global prevalence is 2% to 3%, with a higher incidence in females than males.[8][3][9][10] Community studies conducted in multiple countries, including the United States, have estimated the prevalence to be approximately 2% to 3% in adults, 2% to 5% in adolescents, and 3% among higher education students.[10][11][12]
Requests for cosmetic surgical procedures are common for patients with BDD. An estimated 13% of patients in general cosmetic surgery clinics have BDD.[3] The estimated prevalence of BDD in patients pursuing rhinoplasty is 20%.[3] Approximately 11% of patients seeking orthognathic (jaw) surgery are affected by BDD.[3] Between 5% to 10% of patients requesting orthodontic dentistry treatment are also affected.[3] Individuals with BDD may engage in medical tourism, which involves patients seeking medical treatments and surgeries abroad.[13]
BDD is often a comorbid psychiatric illness among those diagnosed with anxiety, depression, psychotic, or bipolar spectrum disorders. For those with any of these comorbid psychiatric illnesses, the inpatient prevalence of BDD is estimated at 7%, while the outpatient prevalence is approximately 6%.[3] However, individuals with obsessive-compulsive disorder (OCD) or an eating disorder may have a higher prevalence of comorbid BDD.[8]
Pathophysiology
The current understanding of the pathophysiology of BDD is limited. No specific biomarkers are currently available. Some biological findings have been identified as potential clues to identify the illness. Overlapping features discovered from studies of OCD have also provided some insight. Neuroanatomic findings for BDD are inconsistent.[14] Findings of magnetic resonance studies are increased total white matter volume, a leftward shift in caudate volume asymmetry, smaller orbitofrontal cortex, and anterior cingulate volume combined with larger thalamic volumes in patients with BDD compared to controls.[15][16] White matter fiber disorganization in tracts connecting visual processing and emotion and memory processing could explain the severity level of delusional preoccupation, an example of poor insight with misperceived appearance defects.[17]
Results from both functional magnetic resonance imaging (fMRI) and visual processing tasks (Rey-Osterrieth Complex Figure test, inverted faces task, embedded figures task) reveal local or detail-oriented visual processing is enhanced while holistic or global visual processing is diminished in patients with BDD.[18])[19][20] Patients with BDD asked to view certain faces while undergoing a fMRI revealed abnormal patterns of hyperactivity in the left orbitofrontal cortex and bilateral head of the caudate, combined with hypoactivity in the occipital cortex, a visual processing area.[21] One additional fMRI study found patients with BDD had hypoactivity in the dorsal visual and parietal networks compared to healthy controls.[22]
Subjects with BDD have a decreased ability to recognize the emotions of others through facial expressions, an emotional processing deficit. One study found that patients with BDD are likelier to misinterpret neutral facial expressions in photographs as angry.[23] Executive function may also be impaired. Specific areas of difficulty are response inhibition, planning, and decision-making.[24][25] Deficits in executive function combined with neuroimaging findings suggest that subjects with BDD have frontal lobe dysfunction compared to healthy controls.[26]
History and Physical
Patients with BDD have thoughts focused on personal or physical defects that are either very minor or do not exist. These pervasive thoughts are challenging to control and consume an average of 3 to 8 hours daily.[2] Some patients are excessively preoccupied with a single body area. In contrast, others develop preoccupations with multiple body areas, averaging between 5 to 7 different areas of concern.[26] Any physical feature is a potential perceived defect for a patient affected by BDD. The most common concerns revolve around the patient's skin, hair, nose, stomach, breasts, and eyes.[8][26][26][8] Males are more commonly preoccupied with genital size and balding, while females are more likely to focus on areas with body fat, like the breasts, legs, hips, buttocks, and waist.[26]
An all-consuming belief that one appears ugly, deformed, or defective causes emotional turmoil. Repetitive behaviors, or compulsions and rituals, attempt to relieve the psychological stress related to the pervasive thoughts. All patients with BDD display repetitive behaviors at some time during their illness. Common rituals include hiding, camouflaging, mirror checking, excessive grooming, clothes changing, excessive exercise, inspecting, and obtaining reassurance about the concerning body part. Occasionally, the ritualistic behaviors may not be observable by others and are entirely mental rituals like comparing, counting, and self-assuring.
Tangible findings on the mental status examination are variable. Skin or hair-picking wounds may be visible beyond the perceived deficit and camouflaging efforts. The practitioner may witness compulsive behaviors. Affected patients may actively pick their skin, comb their hair, cover the worrisome part of their body, count, or self-reassure.
Although the mental status examination is typically only performed in psychiatric settings, various specialties perform the physical examination. The provider distinguishes between a perceived flaw and an actual physical defect on examination. However, the physical examination should focus on areas where the patient has vocalized their perceived deficit.
Evaluation
BDD is an underrecognized medical. Clues to the presence of BDD are treatment-resistant depression and anxiety, a history of unsuccessful cosmetic procedures, or thinking others are making fun of them. Substance use disorder is primarily intended to alleviate distress and avoid social situations, and the pursuit of unnecessary cosmetic procedures should raise clinical suspicion. Screening in mental health, substance abuse, or any setting where cosmetic procedures occur could improve recognition. The self-report Body Image Disturbance or the Body Dysmorphic Disorder Questionnaires are available.[27][28] Directly ask patients about their symptoms. They will often not divulge them voluntarily.
Individuals with suspected BDD warrant a referral for a psychiatric evaluation. The goals of the initial psychiatric evaluation are to build a relationship of trust, collect historical information in detail related to the presenting problem, and conduct a mental status examination. Psychiatric interview questions should be approached with sensitivity and in a non-judgmental manner. Establishing rapport with a patient affected by BDD is essential, particularly for those with absent insight who may be hesitant to share their history or participate in their treatment plan. The psychiatric evaluation should include focused interview questions that successfully address each of the DSM-5-TR diagnostic criteria for BDD.
Body Dysmorphic Disorder DSM-5-TR Criteria
- Affected patients experience preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or only slightly observable to others.
- Affected patients perform repetitive behaviors.
- The thought preoccupation causes clinically significant distress or impairment in a major life area of functioning.
- An eating disorder does not better explain the thought preoccupation.
If the patient's primary belief is that their muscles or physique is too small, the diagnosis requires a specifier, and "body dysmorphic disorder with muscle dysmorphia" becomes the diagnosis. Patients who also experience panic attacks due to BDD are diagnosed with "body dysmorphic disorder with panic attacks."
Determining the patient's degree of insight into their illness helps to determine treatment course and expectations. Those with good or fair insight recognize that their beliefs about their body are not valid or at least probably not valid. Patients with poor insight believe that their thoughts are likely true. Those with absent insight or delusional beliefs hold firm to their beliefs regardless of what others think.
Laboratory and radiographic imaging are not typically necessary unless the patient has engaged in extreme behaviors that raise concern for their physical health.
Treatment / Management
Patients often seek cosmetic surgical solutions for their perceived physical defects. Providing surgical solutions is not effective. The combination of medications and cognitive behavioral therapy can be effective. Clomipramine and high doses of selective serotonin reuptake inhibitors (SSRI) are first-line pharmacotherapeutic interventions selected based on our knowledge of treating obsessive-compulsive disorder.[29][30] No head-to-head trials have compared the effectiveness of pharmacotherapy with cognitive behavioral therapy (CBT).(A1)
Psychotherapeutic Interventions
Establishing a therapeutic rapport is the cornerstone of treating BDD. Although supportive psychotherapy is unlikely to reduce symptoms of BDD, educating patients about their illness, being an active listener, and providing guidance on the treatments for BDD help to establish trust between the healthcare professional and the patient. This includes educating the patient about their illness, being an active listener, and providing guidance on the treatments for BDD. Patients will often direct the conversation towards how they perceive themself as ugly. Avoid directly focusing on the patient's looks. Instead, after identifying the patient's preoccupation, direct the interview to how this preoccupation impairs critical areas of their daily functioning.[31] Examples are psychological suffering, suicidal thoughts, avoiding social outings, impaired ability to maintain employment or perform well in school, and interpersonal conflicts. Finally, it is crucial to discourage cosmetic interventions, as these rarely resolve BDD symptoms and can cause an increased financial burden along with worsening symptoms.[32]
CBT is a primary intervention for treating BDD.[31][33] Cognitive behavioral therapy directed specifically towards BDD is preferred. Cognitive behavioral therapy utilizes techniques to identify and correct distortive maladaptive beliefs, a core feature of BDD. Specific techniques include education, relaxation exercises, the development of coping skills, and stress management.[31] Although medication interventions are more widely available than access to skilled therapists, there is evidence that telehealth CBT is effective in BDD[34]. These additional treatment routes may continue to improve patients' ability to access CBT services.(A1)
In severe BDD, motivational interviewing may be a helpful tool in assisting a patient who is hesitant to engage in treatment.[35]
Psychotropic Medication Interventions
Because pharmacotherapy is still generally more widely available than psychotherapy, medication-based treatments for BDD are common. Despite none of the following medications having an FDA-labeled indication to treat BDD, there is evidence for their effectiveness to varying degrees. SSRIs are a superior treatment to a placebo.[36] SSRIs are generally well tolerated, making them a favorable choice. However, no evidence suggests that any individual SSRIs may be superior to others. Patients with BDD often require higher doses than those approved by the FDA.[37] For this reason, fluoxetine, sertraline, and escitalopram are good choices.[30] Escitalopram may be a favorable SSRI in patients on multiple medications as it is the least likely SSRI to have drug-drug interactions. Citalopram is generally not recommended to treat BDD because the FDA dosing limit is too low to treat BDD effectively, and high-dose citalopram is associated with QT prolongation.[30][38][39] Paroxetine is generally not as well tolerated as other SSRIs.(A1)
Patients who fail adequate SSRI trials can augment their SSRI therapy with clomipramine. Clomipramine is a tricyclic antidepressant (TCA) with an FDA-labeled indication to treat OCD. Based on randomized trial data, clomipramine is a reasonable adjunctive treatment consideration for BDD.[29] Tricyclic antidepressants have significant adverse effects compared to SSRIs. Clomipramine is generally considered a second-line treatment. Doses of clomipramine exceeding 250mg/d produce bothersome adverse effects. Monitor patients for serotonin syndrome and QT prolongation.[37] (A1)
The current hypothesis is that continuous treatment with clomipramine and SSRIs alters serotonin turnover and neuropeptide expression patterns in the forebrain and midbrain circuits of patients with obsessive-compulsive disorder.[38] Clinically, these pharmacological treatments decrease body dysmorphic preoccupations and compulsive behaviors[40]. Further, SSRIs and TCAs are known effective treatments for depressive and anxiety disorders, which are often present in patients with BDD.[37]
There is limited evidence for recommending other pharmacological treatments to treat BDD. The addition of buspirone, a glutamate modulator (memantine), or a second-generation antipsychotic medication is a potential therapy to add to SSRIs.[41][42][43][44] Monotherapy treatment with venlafaxine has shown some efficacy in a small number of patients.[45][37][40] Single cases reports of bupropion augmentation of SSRIs reported some benefit.[46][47] Considering their potential adverse effects, reports of monoamine oxidase inhibitors use provide inadequate evidence to recommend their use in BDD.[37](B2)
Suicidal ideation and behavior are commonly associated with BDD; patients who have active suicidal ideation or recent suicidal behavior warrant inpatient hospitalization.
Differential Diagnosis
Many symptoms of BDD are present in other psychiatric disorders, and psychiatric comorbidities are common in individuals with BDD. Because of this overlap, BDD is misdiagnosed and underrecognized.
Normal Behavior Appearance Concern
Most individuals have ranging concerns about their appearance, many of which are normal and do not cause pathological symptoms. Normal appearance concerns should not be considered BDD. In normal behavior, there is an absence of obsessive preoccupations, compulsive behaviors, and a lack of psychological distress or impairment of functioning.[35]
Obvious Bodily Defects
Some individuals are preoccupied with bodily defects that are visible to others. When all the other DSM-5-TR diagnostic criteria for BDD are satisfied in these cases, the DSM-5-TR diagnosis is "other specified obsessive-compulsive and related disorder (body dysmorphic-like disorder with actual flaws)." Additionally, BDD's repetitive, compulsive behaviors may result in obvious bodily defects, such as skin picking, leading to skin lesions or scars. Evaluate such patients for a comorbid excoriation (skin-picking) disorder.[35]
Skin Picking (Excoriation) Disorder
Similar to BDD, skin picking (excoriation) disorder also falls under the umbrella of obsessive-compulsive spectrum disorders. Although individuals with BDD may have skin-picking behaviors, the motivation behind the behavior in excoriation disorder is not to improve a perceived appearance deficit.[35]
Trichotillomania (Hair-pulling Disorder)
Trichotillomania, or hair-pulling disorder, falls under the umbrella of obsessive-compulsive spectrum disorders and describes those who have difficulty resisting an urge to control pulling their hair out. Individuals with compulsive hair-pulling behaviors with persistent attempts to improve a perceived bodily deficit should be diagnosed with BDD rather than trichotillomania.[35]
Isolated Dysmorphic Concern
When patients present with a perceived bodily dysmorphic concern without compulsive, repetitive, or ritual behaviors, they do not meet the diagnostic criteria for BDD. A common dysmorphic concern includes the emission of a body odor.[35] Isolated dysmorphic concerns are not a diagnostic entry in the DSM-5-TR or a code in ICD-11.
Obsessive-Compulsive Disorder
Because BDD is under the umbrella of obsessive-compulsive spectrum disorders, obtaining diagnostic clarity between the two illnesses is essential.[48] Both present with obsessions that include intrusive thoughts or preoccupations, persisting for a significant amount of time. These intrusive thoughts impair social and occupational functioning. In both illnesses, the obsessions are difficult to control or resist and are commonly kept secret due to associated shame. The essential difference between obsessive-compulsive disorder and BDD is that in BDD, obsessive thoughts and repetitive behaviors focus on perceived flaws in physical appearance.[49] If patients meet the DSM-5-TR criteria for both BDD and OCD, they should be diagnosed with both appropriately.[50]
Gender Dysphoria
Gender dysphoria and BDD share similarities in that they both include a desire to change a feature of one's physical appearance. This desire results in clinical distress and impairment in social or occupational functioning. The physical appearance in gender dysphoria is focused on primary or secondary sex characteristics, with additional psychological distress from incongruency of the individuals expressed experienced gender.[51]
Eating Disorders
Individuals with anorexia nervosa, bulimia nervosa, and BDD suffer from a distorted body image. Both patients may use harmful behaviors to change their appearance, such as extreme dieting, compensatory behaviors after binge eating, and excessive exercise. Individuals who meet the DSM-5-TR criteria for an eating disorder and BDD are diagnosed with both. However, this occurs after thoroughly ensuring symptoms are not the result of BDD alone or the eating disorder alone.[35]
Major Depressive Disorder
Many individuals with BDD suffer from comorbid major depressive disorder. Patients should be diagnosed with both when meeting the DSM-5-TR diagnostic criteria for both illnesses. Still, many patients who only meet the diagnostic criteria for BDD may suffer from symptoms of anhedonia, difficulties with concentration, guilt, depressed mood, sleep disturbances, and appetite changes.[35]
Social Anxiety Disorder
Due to the fear of being judged by their physical appearance, individuals with BDD may have increasingly reclusive behavior as their illness progresses. Social anxiety disorder (SAD) also presents with similar reclusiveness. The primary concern in SAD is fear of negative valuation of their behavior or speech content.[35] To differentiate these illnesses further, BDD presents with repetitive behaviors, while social anxiety does not. Patients who meet the DSM-5-TR diagnostic criteria for both illnesses should be diagnosed with both.
Delusional Disorder
Individuals with severe BDD and poor insight into their illness may present with delusional beliefs about their physical appearance. In BDD, the thought preoccupation is not required to be delusional but can be simply an exaggeration of an actual minor blemish. Additionally, compulsive behaviors are not characteristic of delusional disorder.[35]
Pertinent Studies and Ongoing Trials
Psychopharmacology is the most readily available treatment vehicle for individuals seeking treatment for BDD, followed by psychotherapeutic interventions. However, both invasive and noninvasive neuromodulation interventions are known as effective treatments for various psychiatric disorders. Studies investigating neuromodulation interventions to treat BDD are minimal.[52] However, there are strong reasons to consider these modalities as potential future therapeutic options for BDD due to the success of deep brain stimulation in treating OCD. Deep brain stimulation requires neurosurgically implanting electrodes that send electrical stimulation to specified brain areas. The complete efficacy of deep brain stimulation for OCD is not established, but the results are promising.[53] Baldermann et al. reported a case of successful treatment for BDD with deep brain stimulation of the ventral capsule, or ventral striatum.[52]
Prognosis
Patients receiving treatment for BDD, including medication, psychotherapy, or a combination of both, are estimated to have a treatment response between 50% and 80% within 4 to 16 weeks.[40][37][54] Maintenance treatment is recommended to prevent relapse, but the length of time for maintenance treatment is unclear.[54]
Complications
Suffering from BDD results in impaired performance in social relationships, emotional processing, and work and school performance.[55] Quality of life associated with BDD is poor.[56] Due to the potential for severe psychosocial impairment associated with BDD, the development of other comorbid psychiatric illnesses is common. Nearly 75% of patients with BDD also have major depressive disorder.[57][58] Other common comorbidities are social anxiety disorder, substance use disorders, obsessive-compulsive disorder, any personality disorder, and eating disorders.[57][58]
The potential for suicidal thoughts and behavior is high. Suicidal ideation is present in nearly 50% of patients affected by BDD.[59]. Suicide attempts are estimated to occur in 1 out of 4 patients with BDD.[59]
Consultations
Multiple American medical organizations have elected for BDD screenings in procedures that patients with BDD commonly seek. The American College of Obstetricians and Gynecologists recommends screening all adolescents seeking breast or labial surgery for BDD; further, consider screening adults seeking female genital cosmetic surgery when appropriate. The American Academy of Otolaryngology lists BDD as a contraindication for elective rhinoplasty, and patients seeking a rhinoplasty should be screened for BDD.
Deterrence and Patient Education
BDD involves an overwhelming preoccupation with a perceived physical defect. Typical areas of concern include the skin, hair, nose, genitalia, breasts, and body shape. These pervasive thoughts are persistent and difficult to control, causing emotional distress and consuming hours each day. Repetitive behaviors like checking oneself in the mirror, grooming, or reassurance-seeking are common attempts to ease the distress.
The symptoms often go undetected and can severely impact one's life. Affected patients often seek cosmetic surgical solutions for their perceived defects. Unfortunately, surgical procedures are ineffective. With the help of a mental health professional, cognitive behavioral therapy, and possibly medications, many patients with BDD see improvement in their symptoms.
Pearls and Other Issues
Optimizing the healthcare professional and patient relationship is essential when treating BDD, particularly for those with poor insight into their condition. Being mindful of the language and tone used during the clinical assessment can significantly impact rapport. Although some patients' perceived deficits might not be visible to others, avoiding the word "imagined" or similar is crucial, as this implies that the clinician believes the patient's symptoms are not real. Expressing empathy throughout the interview encourages patients to continue sharing their symptoms and allows for exploration of how the symptoms are impacting their lives. A careful balance is necessary to avoid minimizing the patient's perceived defect while at the same time not over-emphasizing or telling a patient that their perceived defect is visible if it is not.[40] Avoid arguments with the patient, particularly about the patient's physical appearance. Similar to delusional disorder, it is not helpful to attempt to correct a patient's false fixed belief through arguments; instead, optimize the treatment of the patient's psychiatric symptoms.[60]
Enhancing Healthcare Team Outcomes
BDD is a psychiatric condition marked by a fixation on perceived physical defects, contrary to others' observations. Often undetected, it leads to distress and repetitive actions, potentially escalating to suicidal tendencies. BDD patients may seek unnecessary cosmetic procedures. Understanding diagnostic criteria and implementing evidence-based approaches is crucial across healthcare specialties, given the disorder's underrecognition. Neuroanatomic findings and altered visual processing characterize BDD, contributing to emotional processing deficits and executive function impairment. Screening tools and direct inquiry aid recognition, prompting referral for psychiatric evaluation. Treatment involves psychotherapeutic interventions, primarily cognitive-behavioral therapy, and pharmacotherapy, focusing on selective serotonin reuptake inhibitors and, if necessary, tricyclic antidepressants. Suicidal risk necessitates inpatient care.
An essential component of successfully managing BDD is readily recognizing its clinical presentation. Individuals are more likely to first present to clinicians outside of psychiatry. Dermatology, plastic surgery, primary care, and dentistry healthcare professionals must assist with diagnosis by first screening and identifying BDD. Subsequently, clinicians should make appropriate referrals to psychiatric healthcare professionals and collaborate with both the psychiatric clinician and the psychologist to develop a comprehensive treatment plan.[61] Because insight may be poor in BDD, optimizing the therapeutic relationship is essential in helping patients adhere to their treatment plan.
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