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Body Dysmorphic Disorder
Classification and external resources
ICD-10 F45.2
ICD-9 300.7
DiseasesDB 33723
eMedicine med/3124

Body dysmorphic disorder (BDD) (previously known as Dysmorphophobia[1] is sometimes referred to as body dysmorphia or dysmorphic syndrome[2]) is a (psychological) anxiety disorder in which the affected person is excessively concerned about and preoccupied by a perceived defect in his or her physical features (body image). Depending on the individual case, BDD may either be an anxiety disorder or part of an eating disorder or both: BDD always includes a debilitating or excessive fear of judgement by others, as is seen with social anxiety, social phobia and some OCD problems; or alternately may be a part of eating disorders such as anorexia nervosa, bulimia nervosa and compulsive overeating. Although the term "body dysmorphic disorder" itself describes only those excessive social acceptance fears that relate to one's personal body image. Depending on the individual it may or may not also be part of one of these wider or related syndromes.

The sufferer may complain of several specific features or a single feature, or a vague feature or general appearance, causing psychological distress that impairs occupational and/or social functioning, sometimes to the point of severe depression and anxiety, development of other anxiety disorders, social withdrawal or complete social isolation, and more.[3] It is estimated that 1–2% of the world's population meet all the diagnostic criteria for BDD (Psychological Medicine, vol 36, p 877).

The exact cause(s) of BDD differ(s) from person to person. However, most clinicians believe it could be a combination of biological, psychological and environmental factors from their past or present. Abuse and neglect can also be contributing factors.[4][5]

Onset of symptoms generally occurs in adolescence or early adulthood, where most personal criticism of one's own appearance usually begins, although cases of BDD onset in children and older adults is not unknown. BDD is often misunderstood to affect mostly women, but research shows that it affects men and women equally.[citation needed]

The disorder is linked to significantly diminished quality of life and can be co-morbid with major depressive disorder and social phobia, also known as chronic social anxiety. With a completed-suicide rate more than double than that of major depression, and a suicidal ideation rate of around 80%, BDD is considered a major risk factor for suicide.[citation needed]

A person with the disorder may be treated with psychotherapy, medication, or both. Research has shown cognitive behavioural therapy (CBT) and selective serotonin reuptake inhibitors (SSRIs) to be effective in treating BDD.[citation needed] BDD is a chronic illness and symptoms are likely to persist, or worsen, if left untreated.

Contents

Overview

The Diagnostic and Statistical Manual of Mental Disorders defines body dysmorphic disorder as a preoccupation with an imagined defect in appearance which causes clinically-significant distress or impairment in social, occupational, or other important areas of functioning. However, BDD may involve an actual defect that's slight, but the sufferer constantly obsesses over it. The individual's symptoms must not be better accounted for by another disorder; for example weight concern is usually more accurately attributed to an eating disorder.

The disorder generally is diagnosed in those who are extremely critical of their mirror image, physique or self-image, even though there may be no noticeable disfigurement or defect. The three most common areas that those suffering from BDD will feel critical of have to do with the face: the hair, the skin, and the nose. Outside opinion will typically disagree, and may protest that there even is a defect. The defect exists in the eyes of the beholder, and one with BDD really does feel as if they see something there that is defective.

People with BDD say that they wish that they could change or improve some aspect of their physical appearance even though they are generally of normal or even highly attractive appearance. Body dysmorphic disorder causes sufferers to believe that they are so unspeakably hideous that they are unable to interact with others or function normally for fear of ridicule and humiliation about their appearance. This can cause those with this disorder to begin to seclude themselves or have trouble in social situations. They can become secretive and reluctant to seek help because they fear that others will think them vain or because they feel too embarrassed. It has been suggested that fewer men seek help for the disorder than women.[6]

Ironically, BDD is often misunderstood as a vanity-driven obsession, whereas it is quite the opposite; people with BDD do not believe themselves to be better-looking than others, but instead feel that their perceived "defect" is irrevocably ugly or not good enough. People with BDD may compulsively look at themselves in the mirror or, conversely, cover up and avoid mirrors. They typically think about their appearance for at least one hour a day (and usually more), and in severe cases may drop all social contact and responsibilities as they become a recluse.

A German study has shown that 1–2% of the population meet all the diagnostic criteria of BDD, with a larger percentage showing milder symptoms of the disorder (Psychological Medicine, vol 36, p 877). Chronic low self-esteem is characteristic of those with BDD, because the assessment of self-value is so closely linked with the perception of one's appearance.

BDD is diagnosed equally in men and women, and causes chronic social anxiety for its sufferers.[7]

Phillips & Menard (2006) found the completed-suicide rate in patients with BDD to be 45 times higher than that of the general United States population. This rate is more than double that of those with clinical depression and three times as high as that of those with bipolar disorder.[8] Suicidal ideation is also found in around 80% of people with BDD.[9] There has also been a suggested link between undiagnosed BDD and a higher-than-average suicide rate among people who have undergone cosmetic surgery.[10]

History

The disorder was first documented in 1886 by the researcher Morselli, who dubbed the condition "Dysmorphophobia". BDD was recognized by the American Psychiatric Association in 1987, and was recorded and formally recognized as a disorder in 1987 in the DSM-III-R.

In his practice, Freud had a patient who would today be diagnosed with the disorder: Russian aristocrat Sergei Pankejeff (nicknamed "The Wolf Man" by Freud himself in order to protect Pankejeff's identity), had a preoccupation with his nose to such an extent it greatly limited his functioning.

Diagnoses

According to the DSM IV, to be diagnosed with BDD, a person must fulfill the following criteria:

  • "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 body shape and size in Anorexia Nervosa)."[11]

In most cases, BDD is under-diagnosed. In a study of 17 patients with BDD, BDD was noted in only five patient charts, and none of the patients received an official diagnosis of BDD.[12] This under-diagnosis is due to the disorder only recently being included in DSM IV; therefore, clinician knowledge of the disorder, particularly among general practitioners, is not widespread.[13] Also, BDD is often associated with shame and secrecy; therefore, patients often fail to reveal their appearance concerns for fear of appearing vain or superficial.[13]

BDD is also often misdiagnosed because its symptoms can mimic that of major depressive disorder or social phobia.[14] and so the cause of the individual's problems remain unresolved.

Many individuals with BDD also do not possess knowledge or insight into the disorder and so regard their problem as one of a physical rather than psychological nature; therefore, individuals suffering from BDD may seek cosmetic treatment rather than mental health treatment.

Prevalence

Studies show that BDD is common in not only non-clinical settings but clinical settings as well. A study was performed on 200 people with DSM-IV Body Dysmorphic Disorder, being of age 12 or older and being available to be interviewed in person. They were referred by mental health professionals, friends and relatives, non-psychiatric physicians or responded to advertisements. Out of the subjects, 53 were receiving medication, 33 were receiving psychotherapy, and 48 were receiving both medication and psychotherapy.

The severity of BDD was assessed using the Yale–Brown Obsessive Compulsive Scale modified for BDD, and symptoms were assessed using a Body Dysmorphic Disorder Examination Sheet. Both tests were designed specifically to assess BDD. The results showed that BDD occurs in 0.7–1.1% of community samples and 2–13% of non-clinical samples. 13% of psychiatric inpatients were diagnosed with BDD.[15] Some of the patients initially diagnosed with obsessive-compulsive disorder (OCD) had BDD, as well.

53 patients with OCD and 53 patients with BDD were compared on clinical features, comorbidity, family history, and demographic features. Nine of the 62 subjects (14.5%) of those with OCD also had BDD.[16]

Comorbidity

There is a high degree of comorbidity with other psychological disorders, often resulting in misdiagnoses by clinicians. Research suggests that around 76% of people with BDD will experience major depressive disorder at some point in their lives,[17][citation needed] significantly higher than the 10–20% expected in the general population. Around 37% of people with BDD will also experience social phobia[17] and around 32% suffer from obsessive–compulsive disorder.[17] The most common personality disorders found in individuals with BDD are avoidant personality disorder and dependent personality disorder, which conforms to the introverted, shy and neurotic traits usually found in BDD sufferers.

Eating disorders, such as anorexia nervosa and bulimia nervosa, are also sometimes found in people with BDD (usually in the females), as are trichotillomania, dermatillomania, and sub-type disorders Olfactory Reference Syndrome and muscle dysmorphia.[17]

Common symptoms and behaviors

There are many common symptoms and behaviors associated with BDD. Often, these symptoms and behaviours are determined by the nature of the BDD sufferer's perceived defect; for example, use of cosmetics is most common in those with a perceived skin defect. Due to this perception dependency, many BDD sufferers will only display a few common symptoms and behaviors.

Symptoms

Common symptoms of BDD include:

  • Obsessive thoughts about (a) perceived appearance defect(s).
  • Obsessive and compulsive behaviors related to perceived appearance defect(s) (see section below).
  • Feeling self-conscious in social environments; thinking that others notice and mock their perceived defect(s).
  • Strong feelings of shame.
  • Avoidant personality: avoiding leaving the home, or only leaving the home at certain times, for example, at night.
  • Inability to work or an inability to focus at work due to preoccupation with appearance.
  • Decreased academic performance (problems maintaining grades, problems with school/college attendance).
  • Problems initiating and maintaining relationships (both intimate relationships and friendships).
  • Repetitive behavior (such as constantly (and heavily) applying make-up; regularly checking appearance in mirrors; see section below for more associated behavior).
  • Seeing slightly varying image of self upon each instance of observal in a mirror or reflective surface.
  • Note: any kind of body modification may change one's appearance. There are many types of body modification that do not include surgery/cosmetic surgery. Body modification (or related behavior) may seem compulsive, repetitive, or focused on one or more areas or features that the individual perceives to be 'defect'.

Compulsive behaviors

Common compulsive behaviors associated with BDD include:

  • Compulsive mirror checking, glancing in reflective doors, windows and other reflective surfaces.
  • Alternatively, an inability to look at one's own reflection or photographs of oneself; also, the removal of mirrors from the home.
  • Attempting to camouflage the imagined defect: for example, using cosmetic camouflage, wearing baggy clothing, maintaining specific body posture or wearing hats.
  • Use of distraction techniques: an attempt to divert attention away from the person's perceived defect, e.g. wearing extravagant clothing or excessive jewelry.
  • Compulsive skin-touching, especially to measure or feel the perceived defect.
  • Becoming hostile toward people for no known reason, especially those of the opposite sex.
  • Seeking reassurance from loved ones.
  • Self-harm
  • Comparing appearance/body parts with that/those of others, or obsessive viewing of favorite celebrities or models whom the person suffering from BDD wishes to resemble.
  • Compulsive information-seeking: reading books, newspaper articles and websites that relate to the person's perceived defect, e.g. hair loss or being overweight.
  • In extreme cases, patients have attempted to perform plastic surgery on themselves, including liposuction and various implants with disastrous results.

source: The Broken Mirror, Katharine A Philips, Oxford University Press, 2005 ed

Common locations of perceived defects

In research carried out by Dr. Katharine Philips, involving over 500 patients, the percentage of patients concerned with the most common locations were as follows;

  • Skin (73%)
  • Hair (56%)
  • Nose (37%)
  • Toes (36%)
  • Weight (22%)
  • Abdomen (22%)
  • Breasts/chest/nipples (21%)
  • Eyes (20%)
  • Thighs (20%)
  • Teeth (20%)
  • Legs (overall) (18%)
  • Body build/bone structure (16%)
  • Facial features (general) (14%)
  • Face size/shape (12%)
  • Lips (12%)
  • Buttocks (12%)
  • Chin (11%)
  • Eyebrows (11%)
  • Hips (11%)
  • Ears (9%)
  • Arms/wrists (9%)
  • Waist (9%)
  • Genitals (8%)
  • Cheeks/cheekbones (8%)
  • Calves (8%)
  • Height (7%)
  • Head size/shape (6%)
  • Forehead (6%)
  • Feet (6%)
  • Hands (6%)
  • Jaw (6%)
  • Mouth (6%)
  • Back (6%)
  • Fingers (5%)
  • Neck (5%)
  • Shoulders (3%)
  • Knees (3%)
  • Toes (3%)
  • Ankles (2%)
  • Facial muscles (1%)

source: The Broken Mirror, Katharine A Philips, Oxford University Press, 2005 ed, p56

People with BDD often have more than one area of concern.

Development

BDD usually develops in adolescence, a time when people are generally most sensitive about their appearance. However, many patients suffer for years before seeking help. An absolute cause of body dysmorphic disorder is unknown. However, research shows that a number of factors may be involved and that they can occur in combination.

Some of the theories regarding the cause of BDD are summarized below.

Biological/genetic

  • Chemical imbalance in the brain: An insufficient level of serotonin, one of the brain's neurotransmitters involved in mood and pain, may contribute to BDD. Although such an imbalance in the brain is unexplained, it may be hereditary.

Serotonin is thought to have a role in regulating anxiety, though it is also thought to be involved in such processes as sleep and memory function.

Serotonin belongs to the neurotransmitter class of molecules that transfer (chemical) signals between nerve cells. Upon a trigger, the relevant neurotransmitter is released into the neural synapse and must then bind to the receptor sites located on the neighboring nerve cell. It is hypothesized that BDD sufferers may have blocked or damaged receptor sites that prevent serotonin from functioning to its full potential.[18] This theory is supported by the fact that many BDD patients respond positively to selective serotonin reuptake inhibitors (SSRIs) – a class of antidepressant medications that prevent serotonin re-uptake from the neural synapse, thus generating higher local levels of serotonin.[18] There are cases, however, of patient's BDD symptoms worsening from SSRI use.[18] Imbalance in levels of other neurotransmitters, such as Dopamine and Gamma-aminobutyric acid, have also been proposed as contributory factors in the development of BBD.[18]

  • Genetic predisposition:

It has been suggested that certain genes may predispose an individual to developing BDD. This theory is supported by the fact that approximately 20% of people with BDD have at least one first-degree relative, such as a parent, child or sibling, who also has the disorder.[19] It is not clear, however, whether this is genetic or due to environmental factors (i.e. learned traits rather than inherited genes). Twin studies suggest that the majority, if not all, mental disorders are influenced, at least to some extent, by genetics and neurobiology, although no such studies have been conducted specifically for BDD.[19]

  • Brain regions:

A further biologically-based hypothesis for the development of BDD is the presence of abnormalities in certain brain regions. Magnetic resonance imaging (MRI)-based studies found that individuals with BDD may have abnormalities in brain regions similar to those found in OCD.[20]

  • Visual processing:

While some believe that BDD is caused by an individual's distorted perception of his or her actual appearance, others have hypothesized that people with BDD actually have a problem processing visual information. This theory is supported by the fact that individuals who are treated with SSRI's often report that their defect has gone—that they no longer see it. However, this may be due to a change in the individual's perception, rather than a change in the visual processing itself.[21] (Countering this hypothesis is, also, the fact that, if BDD were caused by an 'organic' visual information processing anomaly, this would mean the BDD sufferer would perceive other people distorted as well; no 'defect' would thus remain, compared to the assumed-normal population.)

  • Obsessive–compulsive disorder.

BDD often occurs with OCD, where the patient uncontrollably practices ritual behaviors that may literally take over his or her life. A history of, or genetic predisposition to obsessive–compulsive disorder may make people more susceptible to BDD.

  • Generalized anxiety disorder.

BDD may co-exist with generalized anxiety disorder. This condition involves excessive worrying that disrupts the patient's daily life, often causing exaggerated or unrealistic anxiety about life's circumstances, such as a perceived flaw or defect in appearance, as in BDD.

Psychological

  • Teasing or criticism:

It has been suggested that teasing or criticism regarding appearance could play a contributory role in the onset of BDD. While it is unlikely that teasing causes BDD (since the majority of individuals are teased at some point in their life), it may act as a trigger in individuals who are genetically or environmentally predisposed; likewise, extreme levels of childhood abuse, bullying and psychological torture are often rationalized and dismissed as "teasing," sometimes leading to traumatic stress in vulnerable persons.[22] Around 60% of people with BDD report frequent or chronic childhood teasing.[22]

  • Parenting style:

Similarly to teasing, parenting style may contribute to BBD onset; for example, parents who either place excessive emphasis on aesthetic appearance, or disregard it at all, may act as a trigger in the genetically-predisposed.[22]

  • Other life experiences:

Many other life experiences may also act as triggers to BDD onset; for example, neglect, physical and/or sexual trauma, insecurity and rejection.[22]

Environmental

  • Media:

It has been theorised that media pressure may contribute to BBD onset; for example, glamour models and the implied necessity of aesthetic beauty. However, BDD occurs in all parts of the world, including isolated areas where access to media is limited or (practically) non-existent. Media pressure is therefore an unlikely cause of BDD, although it may act as a trigger in those already genetically predisposed or could worsen existing BDD symptoms.[23]

Personality

Certain personality traits may make someone more susceptible to developing BDD. Personality traits which have been proposed as contributing factors include: [24]

Since personality traits among people with BDD vary greatly, it is unlikely that these are the direct cause of BDD. However, like the aforementioned psychological and environmental factors, they may act as triggers in individuals.[24]

Social effects of BDD

The effects of BDD can range from slightly cumbersome to severely debilitating. It can make normal employment or family life impossible. Those who do have regular employment or carry family responsibilities would almost certainly find life more productive and satisfying without BDD. The partners and family of sufferers of BDD may also become involved and suffer greatly, sometimes losing their loved one to suicide.

Studies have shown a positive correlation between BDD symptoms and poor quality of life. An indicator of just how seriously this disorder can affect a human being is the fact that the quality of life for individuals with BDD has also been shown to be poorer than for those with major depressive disorder, dysthymia, obsessive–compulsive disorder, social phobia, panic disorder, premenstrual dysphoric disorder and post-traumatic stress disorder.[25]

Because the onset of BDD typically lies in adolescence, an individual's academic and/or social performance may be significantly affected. Depending on the severity of symptoms, an individual may experience great difficulty maintaining grades and attendance or, in severe cases, may drop out of school and not reach full (academic) potential. The vast majority of people with BBD (90%) say that their disorder impacts on their academic and/or occupational functioning,[9] while 99% say that their disorder impacts on their social functioning.[9]

Despite a normal (or even strong) desire for relationships with other people, many BDD sufferers will instead choose isolation rather than risk being rejected or humiliated (due to their perceived appearance) in social interaction. Many people with BDD also have coexisting social phobia and/or avoidant personality disorder, making the sufferer's ability to establish relationships even more difficult.

Sufferers of BDD may often find themselves getting almost 'stuck' in procrastination - in some cases, they therefore appear to take a long time to get everything done. However, contrary to the usually low self-motivation, it is common to exhibit a fanatic and extreme approach when the action is relevant to the person's image, fully applying attention to the tasks at hand and at self-grooming and/or modification.

Prognosis

Many individuals with BDD have repeatedly sought treatment from dermatologists or cosmetic surgeons with little satisfaction before finally accepting psychiatric or psychological help. Plastic surgery on these patients can lead to manifest psychosis, suicidal tendencies or never-ending requests for more surgery. [26][27] Treatment can improve the outcome of the illness for most people; some may function reasonably well for a time and then relapse, while others may remain chronically ill. Outcome without therapy has not been researched, but it is thought the symptoms persist unless treated.[citation needed]

Treatment

Studies have found that Cognitive Behavior Therapy (CBT) has proven effective. In a study of 54 BDD patients who were randomly assigned to Cognitive Behavior Therapy or no treatment, BDD symptoms decreased significantly in those patients undergoing CBT. BDD was eliminated in 82% of cases at post treatment and 77% at follow-up.[28]

Due to believed low levels of serotonin in the brain, another commonly used treatment is SSRI drugs (Selective Serotonin Reuptake Inhibitor). 74 subjects were enrolled in a placebo-controlled study group to evaluate the efficiency of fluoxetine hydrochloride (Prozac); patients were enrolled in a 12-weeks, double-blind, randomized study. At the end of treatment, 53% of patients responded to the fluoxetine.[29] In extreme cases patients are referred for surgery as this is seen as the only solution after years of other treatments and therapy.

See also

References

  1. ^ Berrios G E, Kan CS (July 1996). "A conceptual and quantitative analysis of 178 historical cases of dysmorphophobia". Acta Psychiatr Scand 94 (1): 1–7. doi:10.1111/j.1600-0447.1996.tb09817.x. PMID 8841670. 
  2. ^ Odom, Richard B.; Davidsohn, Israel; James, William D.; Henry, John Bernard; Berger, Timothy G.; Clinical diagnosis by laboratory methods; Dirk M. Elston (2006). Andrews' diseases of the skin: clinical dermatology (10th ed.). Saunders Elsevier. ISBN 0-7216-2921-0. 
  3. ^ American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (text revision). Washington, DC: Author
  4. ^ Didie, E.R., Tortolani, C.C., Pope, C.G, Menard, W., Fay, C., & Phillips, K.A. (2006). Childhood abuse and neglect in body dysmorphic disorder. Child Abuse & Neglect, 30, 1105-1115
  5. ^ Neziroglu, F., Khemlani-Patel, S., & Yaryura-Tobias, J.A. (2006). Rates of abuse in body dysmorphic disorder and obsessive compulsive disorder. Body Image, 3, 189-193
  6. ^ Phillips, K. A. (1996). The broken mirror Understanding and treating body dysmorphic disorder. p141 New York: Oxford University Press.
  7. ^ http://www.lipo.com/Health_Articles/Lifestyle_Articles/When_the_mirror_lies_-_Body_dysmorphic_disorder_(dysmorphophobia)_on_the_rise_and_taking_lives./
  8. ^ Suicidality in Body Dysmorphic Disorder: A Prospective Study. Phillips and Menard 163 (7): 1280. Am J Psychiatry
  9. ^ a b c Phillips, K. A. (1996). The Broken Mirror: Understanding and treating body dysmorphic disorder. p119 New York: Oxford University Press.
  10. ^ Cosmetic surgery special: When looks can kill – health – 19 October 2006 – New Scientist
  11. ^ American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders, 468 Washington, D.C.: Author.
  12. ^ Rosen JC; Reiter, Jeff; Orosan, Pam (1995). "Cognitive-behavioral body image therapy for body dysmorphic disorder". Journal of Consulting Psychology 63: 263–9. doi:10.1037/0022-006X.63.2.263. 
  13. ^ a b Phillips, K. A. (1996). The Broken Mirror: Understanding and treating body dysmorphic disorder. p39 New York: Oxford University Press.
  14. ^ Phillips, K. A. (1996). The Broken Mirror: Understanding and treating body dysmorphic disorder. p47 New York: Oxford University Press.
  15. ^ Phillips, K. A., Menard, W., Fay, C., & Weisberg, R (2006). "Demographic characteristics, phenomenology, comorbidity, and family history in 200 individuals with body dysmorphic disorder". Pyschomatics 46 (4): 317–25. doi:10.1176/appi.psy.46.4.317. PMID 16000674. 
  16. ^ Phillips KA, Gunderson CG, Mallya G, McElroy SL, Carter W (November 1998). "A comparison study of body dysmorphic disorder and obsessive-compulsive disorder". J Clin Psychiatry 59 (11): 568–75. PMID 9862601. 
  17. ^ a b c d Phillips, K. A. (1996). The Broken Mirror: Understanding and treating body dysmorphic disorder. p391 New York: Oxford University Press.
  18. ^ a b c d Phillips, K. A. (1996). The Broken Mirror: Understanding and treating body dysmorphic disorder. p162–164 New York: Oxford University Press.
  19. ^ a b Phillips, K. A. (1996). The Broken Mirror: Understanding and treating body dysmorphic disorder. p164–165 New York: Oxford University Press.
  20. ^ Phillips, K. A. (1996). The Broken Mirror: Understanding and treating body dysmorphic disorder. p165–167 New York: Oxford University Press.
  21. ^ Phillips, K. A. (1996). The Broken Mirror Understanding and treating body dysmorphic disorder. p195–197 New York: Oxford University Press.
  22. ^ a b c d Phillips, K. A. (1996). The Broken Mirror: Understanding and treating body dysmorphic disorder. p170–173 New York: Oxford University Press.
  23. ^ Phillips, K. A. (1996). The Broken Mirror: Understanding and treating body dysmorphic disorder. p176–180 New York: Oxford University Press.
  24. ^ a b Phillips, K. A. (1996). The broken mirror Understanding and treating body dysmorphic disorder. p173–175 New York: Oxford University Press.
  25. ^ Phillips, K. A. (1996). The Broken Mirror: Understanding and treating body dysmorphic disorder. p130 New York: Oxford University Press.
  26. ^ Phillips KA, Dufresne RG (March 2002). "Body dysmorphic disorder: a guide for primary care physicians". Prim. Care 29 (1): 99–111, vii. PMID 11856661. 
  27. ^ http://www.veale.co.uk/bddrefs.html
  28. ^ Orosan, P., Reiter, J., Rosen, J. (1995). Cognitive-behavioral body image therapy for body dysmorphic disorder. Journal of Consulting and Clinical Psychology, 63(2), 263-269.
  29. ^ Phillips KA, Albertini RS, Rasmussen SA (April 2002). "A randomized placebo-controlled trial of fluoxetine in body dysmorphic disorder". Arch. Gen. Psychiatry 59 (4): 381–8. doi:10.1001/archpsyc.59.4.381. PMID 11926939. http://archpsyc.ama-assn.org/cgi/content/full/59/4/381. 
  • Sabine Wilhelm (2006). Feeling Good about the Way You Look: A Program for Overcoming Body Image Problems. New York: The Guilford Press. ISBN 1-57230-730-7. 
  • Phillips, Katharine A. (2005). The broken mirror: understanding and treating body dysmorphic disorder (Revised and Expanded ed.). Oxford [Oxfordshire]: Oxford University Press. ISBN 0-19-516719-8. 
  • Barlow, David (2005). Essentials of Abnormal Psychology (with CD-ROM) (4th ed.). Belmont, CA: Wadsworth Publishing. ISBN 0-495-03128-3. 
  • Neziroglu F, Roberts M, Yayura-Tobias JA (2004). "A behavioral model for body dysmorphic disorder". Psychiatric Annals 34 (12): 915–20. 
  • Phillips KA (1 September 1991). "Body dysmorphic disorder: the distress of imagined ugliness". Am J Psychiatry 148 (9): 1138–49. PMID 1882990. http://ajp.psychiatryonline.org/cgi/content/abstract/148/9/1138. 
  • Cherry Pedrick; James Claiborn (2002). The BDD Workbook: Overcoming Body Dysmorphic Disorder and End Body Image Obsessions. Oakland, Calif: New Harbinger Publications. ISBN 1-57224-293-0. 
  • Phillips KA (February 2004). "Body dysmorphic disorder: recognizing and treating imagined ugliness". World Psychiatry 3 (1): 12–7. PMID 16633443. 
  • Phillips, Katharine A.; Castle, David J. (2002). "Body dysmorphic disorder". Disorders of Body Image. Hampshire: Wrightson Biomedical. ISBN 1-871816-47-5. 
  • Grant JE, Kim SW, Crow SJ (July 2001). "Prevalence and clinical features of body dysmorphic disorder in adolescent and adult psychiatric inpatients". J Clin Psychiatry 62 (7): 517–22. PMID 11488361. 
  • Phillips KA, Nierenberg AA, Brendel G, Fava M (February 1996). "Prevalence and clinical features of body dysmorphic disorder in atypical major depression". J. Nerv. Ment. Dis. 184 (2): 125–9. doi:10.1097/00005053-199602000-00012. PMID 8596110. 
  • Perugi G, Akiskal HS, Lattanzi L, et al. (1998). "The high prevalence of "soft" bipolar (II) features in atypical depression". Compr Psychiatry 39 (2): 63–71. doi:10.1016/S0010-440X(98)90080-3. PMID 9515190. 
  • Zimmerman M, Mattia JI (1998). "Body dysmorphic disorder in psychiatric outpatients: recognition, prevalence, comorbidity, demographic, and clinical correlates". Compr Psychiatry 39 (5): 265–70. doi:10.1016/S0010-440X(98)90034-7. PMID 9777278. 
  • Phillips KA, McElroy SL, Keck PE, Pope HG, Hudson JI (February 1993). "Body dysmorphic disorder: 30 cases of imagined ugliness". Am J Psychiatry 150 (2): 302–8. PMID 8422082. 

Further reading

  • Westwood, S. 'Suicide Junkie' Living and surviving body dysmorphic disorder, borderline personality, self harm and suicide. 2006
  • Saville, Chris. "The Worried Well." Body Dysmorphic Disorder. Films for the Humanities & Sciences, Princeton, NJ. 1997. Video Archive. 2004.
  • Walker, Pamela. "Everything You Need To Know About Body Dysmorphic Disorder." New York: The Rosen Publishing Group, Inc., 1999.
  • Phillips, Katharine A. (1996). The broken mirror: understanding and treating body dysmorphic disorder. Oxford [Oxfordshire]: Oxford University Press. ISBN 0-19-508317-2. 
  • Thomas F. Cash Ph.D., "The Body Image Workbook, 2nd. ed.", New Harbinger Publications, 2008
  • Veale, David and Willson, Rob. "Overcoming Body Shame and Body Dysmorphic Disorder": Robinson, (forthcoming mid 2007)
  • The BBC documentary "Too Ugly For Love" is available from UK charity The BDD Foundation
  • TV documentary by former BDD sufferer John Furse available from Films Of Record (020 7286 0333)

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Simple English

Body dysmorphic disorder (BDD) is a mental problem where people think they look different to how they really look. People are usually said to have BDD if they are extremely critical of their body, even though there may be nothing noticeably wrong with it. If there is something wrong with their body, it is usually so small that a person without BDD would not be unhappy about it at all[1].

Most people without BDD may not like some parts of their body, but people with BDD, believe that they are so ugly, even though they are not, that they find it difficult to talk or exist with other people, or live normally, scared that other people will be mean to them because of the way they look. People with BDD often do not look for help because they are afraid others will think they are just vain, or they may feel too embarrassed to talk to other people as they think they are so ugly.

BDD has obsessive and compulsive parts, so it is an Obsessive-compulsive disorder. People with BDD may look at themselves in the mirror too much, or some people with BDD may actually try not to look in the mirror. Both of these are possible for a person with BDD. They usually think about their body for more than one hour per day, and in bad cases, can stop talking to other people, and may stay at home. People with BDD often have very low self-confidence, because they believe that a person's value is linked to what they look like, and because they do not think that they are beautiful themselves, they do not think they have much value.

Contents

History

  • In 1886, BDD was first written about by the researcher 'Morselli', who named it Dysmorphophobia.
  • In 1987, BDD was first properly seen by the American Psychiatric Association.
  • In 1997, BDD was first recorded and formally seen as a mental problem in the Diagnostic and Statistical Manual of Mental Disorders (DSM).

Sigmund Freud had an important Russian person (Sergei Pankejeff) with him in the past, who would have been classified as having the disorder in modern times. Freud named him "The Wolf Man", to protect Pankejeff's identity. Pankejeff was so unhappy with his nose that he could not live a normal life.

Cause

It is unknown what the full cause of BDD is. However, research shows that a number of things may be the cause:

The chemicals in the brain. If the amount of serotonin is too low, one of the brain's neurotransmitters which gives us 'mood' and 'pain', may help cause body dysmorphic disorder. Scientists can not explain this chemical problem in the brain, but it may be hereditary (passed down from parents to child).

Obsessive-compulsive disorder. People with BDD also have OCD, where the person does things without wanting to. If people have had, or have a genetic link to OCD, the person may be more likely to have BDD.

Generalized anxiety disorder. People with BDD may also have generalized anxiety disorder. This disorder is where the person worries about things a lot, which makes them have anxiety about things in their life, for example, about their body, as in BDD.

Development

[[File:|100px|thumb|Adolescence is a time where the body goes through many changes, such as acne, and these can be difficult for people, and this is when BDD begins]] BDD usually develops in adolescence, a time when people usually worry about their appearance the most. However, many people with BDD suffer for years before they look for help. When they do look for help to Doctors, people with the problem often say they have other problems, for example, depression, social anxiety, or obsessive-compulsive disorder, but do not say their real problem is with the way they look. Most patients can not be convinced that the problem they have with their body is only 'imagined', and that they are seeing a 'changed' view of their, because people do not know much about BDD, compared to other mental problems, for example OCD or others.

Diagnosis

The DSM (Diagnostic and Statistical Manual of Mental Disorders) IV says that a person must have the things written below if they have BDD:

  • Being unhappy with an imagined problem on their body. If a small problem is there, the person is unhappy with it more than they should be.
  • The unhappiness causes large problems in talking to other people, having a job, or living a normal life.
  • The unhappiness is not caused by a different mental problem (for example, unhappiness with weight in Anorexia Nervosa)[2].

Features of BDD

File:Mirror
People with BDD spend hours getting ready to go out

[[File:|right|thumb|150px|Make up is often used to cover up the imagined 'problems']]

A person with BDD will often do these things:

  • Look in the mirror a lot, look in reflective doors, windows and other reflective surfaces.
  • If the person does not look in the mirror a lot, they will try not to look in the mirror or at photographs ever, and will often not have mirrors in their home.
  • Touch their skin a lot to feel the 'imagined' problem.
  • Wanting other people to say good things to them about the way they look a lot.
  • Asking other people about the way they look a lot.
  • Not talk to people a lot.
  • Not having much confidence
  • Comparing the way they look to people they want to look like a lot. This may be of celebrities, or people in their life.
  • Doing exercise or having diets more than normal.
  • Doing these things a lot: combing hair, plucking eyebrows, shaving, etc.
  • Using medicine to change the body shape and body size.
  • Wanting plastic surgery or more than one plastic surgery, more than normal.
  • In some extreme examples, patients have tried to do plastic surgery to themself.

Where on the body the 'imagined' problem can be

Dr. Katharine Philips did research, with more than 500 people with BDD, on the percentage of patients unhappy with the most common parts of the body;

source: The Broken Mirror, Katharine A Philips, Oxford University Press, 2005 ed, p56

However, people with BDD often are unhappy about more than one part of their body.

Numbers of people

A German study has shown that 1-2% of the population has complete BDD, but a bigger percentage of people show some of the effects (Psychological Medicine, vol 36, p 877).

The number of men and women with BDD is around the same, but there are slightly more women with it. However, the number of men and women who go to the doctor with it are the same[3].

Studies show that BDD is common non-clinical places and clinical places. Research was done on 200 people with DSM-IV BDD. These people were aged 12 and older. They were interviewed. The people with BDD were found from 'mental-health doctors', advertisements, their friends and family, and non-psychiatrist physicians. 53 of the 200 people were receiving medication, 33 were receiving psychotherapy, and 48 were receiving both medication and psychotherapy. How bad each person's BDD was, was assessed using the "Yale-Brown Obsessive Compulsive Scale", modified for BDD. Symptoms were assessed with the Body Dysmorphic Disorder Examination. Both tests were made just for BDD. The results showed that BDD is in 0.7% - 1.1% of community samples and 2%-13% of non-clinical samples. 13% of psychiatric patients had BDD[4]. Research also found that some of the patients who were firstly diagnosed with OCD, also had BDD. 53 patients with OCD and 53 patients with BDD were compared to each other in research. Clinical features, comorbidity, family history, and population features were compared between the two groups. 9 of the 62 subjects (14.5%) of those with OCD also had BDD[5].

In most examples, BDD is not found even when people have it. In research done on 17 patients with BDD, BDD was 'found' in only five patients, and none of the patients had a proper diagnosis of BDD even though they all in fact had BDD[6].

Problems caused by BDD

BDD can cause only a few problems for some people. However, for other people, it can cause many problems.

Responsibilities

File:Family trip to
Family life can become difficult when someone has BDD

It can make it very difficult to have a normal job or family life. People who have a job or a family to care for would definitely find life easier and better if they did not have BDD. The love partners of BDD people can also suffer, as they may sometimes lose their loved one to suicide. Friendship, romance, and family is very hard to hold for a person with BDD, as the unhappiness with the looks of the person takes over their life, so they often do not bother with the other aspects of life as much. Also, the BDD stops the person from making these 'bonds' with people, as they always feel scared about the way they look, and therefore find it difficult to be themself with other people.

Motivation

People with BDD may often have little motivation for anything. This means that BDD people can appear to take a long time to get everything done. However, this is not exactly true, because BDD sufferers will often just stop what they were doing for a long time, so it is not just that they are slow, but find it difficult to concentrate on what they are doing. without being able to actually motivate themselves until it becomes completely necessary to get back up. This low amount of motivation can be in all parts of a person's life, for example, school, friends, love, family, or work.

However, when the person is trying to do things to the way they look, such as combing their hair, or choosing clothes, it is common for the person to have an extreme motivation. Therefore, people with BDD can sometimes not feel motivated for anything in their life, but when they are working on their looks, they will have an extreme motivation that is not normal either.

Suicide

File:Spirulina
Suicide rates are very high for people with BDD

People with BDD have a very high suicide rate compared to all mental problems.

Phillips & Menard did a lot of research in 2006 about BDD suicides.

  • They found that the percentage of people in the USA with BDD who commit suicide is 45 times higher than the percentage of all the USA population who commit suicide.
  • The percentage of people in the USA with BDD who commit suicide is more than 2 times higher than the percentage of people in the USA with depression who commit suicide.
  • The percentage of people in the USA with BDD who commit suicide is 3 times higher than the percentage of people in the USA with bipolar disorder who commit suicide.[7].

Some people say that there is a link between undiagnosed BDD and a higher than average suicide rate with people who had cosmetic surgery[8].

A similar mental problem, Gender identity disorder (GID), where the person doesn not like his, her, or its gender as a male or female etc, often has BDD-like feelings that are only at sexual features on their body, which disagree with the person's gender in their head. The fact that people with GID also have BDD features, means that people with GID have an estimated suicide attempt rate of 20%. The suicide attempt rate for patients with only BDD is 15%.[9][10]

Vanity

File:Reverso de
People with BDD often look at their reflection in anything shiny, like mirrors, windows, CDs, screens, etc

BDD is often wrongly thought of as a 'vanity' obsession, but it is actually the opposite, because people with BDD believe they are very ugly, even though people without BDD do not think they are. There is not usually actually anything wrong with the way the person with BDD looks, but to that person, there is. A person with BDD can spend hours looking in the mirror, but they are not being vain, as they do not think they are attractive. People with BDD usually realize that worrying about their looks so much is bad, but they can not help it[3].

Treatments

Research found that talking as therapy, has not worked to stop BDD. However, Cognitive Behavior Therapy (CBT) has been found to be more effective. In a study of 54 patients with BDD, some of them had Cognitive Behavior Therapy, and some had no treatment. BDD symptoms decreased a lot in those patients undergoing CBT. BDD was eliminated in 82% of cases at post treatment and 77% at follow-up. (8) Due to low levels of serotonin in the brain, another commonly used treatment is SSRI drugs (Selective Serotonin Reuptake Inhibitor). 74 subjects were enrolled in a placebo controlled study group to evaluate the efficiency of fluoxetine hydrochloride, a SSRI drug. Patients were randomized to receive 12-weeks of double-blind treatment with fluoxetine or the placebo. At the end of 12 weeks, 53% of patients responded to the fluoxetine.[11]

Body Dysmorphic Disorder is a chronic disease that has symptoms that never subside. Instead, they get worse as time goes on. Without treatment, BDD could last a lifetime. In many cases, as illustrated in The Broken Mirror by Katharine Phillips, the social lives of many patients disintegrates because they are so preoccupied with their appearance.[12]

Famous people with BDD

Other pages

References

  1. 1.0 1.1 When the mirror lies - Body dysmorphic disorder (dysmorphophobia) on the rise and taking lives. ; Lipo; 2006-08-24; retrieved on 2007-01-10
  2. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders, 468 Washington, D.C.: Author.
  3. 3.0 3.1 Dr Veale, David; Body Dysmorphic Disorder - FAQ; Ethan Frome; retrieved on 2007-01-10
  4. Phillips, K. A., Menard, W., Fay, C., & Weisberg, R. (2006). Demographic characteristics, phenomenology, comorbidity, and family history in 200 individuals with body dysmorphic disorder [Electronic version]. Pyschomatics, 46, 317-325.
  5. Phillips, K. A., Gunderson, C. G., Mallya, G., McElroy, S. L., Carter, W. (1978). Physicians Postgraduate Press: A comparison study of body dysmorphic disorder and obsessive-compulsive disorder. The Journal of Clinical Psychiatry. Retrieved December 10, 2007, from http://archpsyc.highwire.org/cgi/content/56/11/1033
  6. Rosen, J. C. (1995). Cognitive-behavioral body image therapy for body dysmorphic disorder [Electronic version]. Journal of Consulting Psychology, 63, 263-269.
  7. "Suicidality in Body Dysmorphic Disorder: A Prospective Study". American Psychiatric Association. http://ajp.psychiatryonline.org/cgi/content/full/163/7/1280. Retrieved 2008-01-10. 
  8. http://www.newscientist.com/channel/health/mg19225745.200-cosmetic-surgery-special-when-looks-can-kill.html
  9. Seattle and King County Health - Transgender Health
  10. Katharine A. Phillips, MD Suicidality in Body Dysmorphic Disorder Primary Psychiatry. 2007;14(12):58-66
  11. Phillips, K. A., Albertini, R. S., Rasmussen, S. A. (2002). A randomized placebo-controlled trial of fluoxetine in body dysmorphic disorder. Arch Gen Psychiatry. Retrieved December 10, 2007, from http://archpsyc.ama-assn.org/cgi/content/full/59/4/381?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=Body+Dysmorphic+Disorder&searchid=1&FIRSTINDEX=0&resourcetype=HWCIT
  12. Phillips, K. A. (1996). The broken mirror Understanding and treating body dysmorphic disorder. New York: Oxford University Press.







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