Body dysmorphic disorder
Body dysmorphic disorder (BDD), also known in some contexts as dysmorphophobia, is a mental disorder defined by an overwhelming preoccupation with a perceived flaw in one's physical appearance.[1] In BDD's delusional variant, the flaw is imagined.[2] When an actual visible difference exists, its importance is disproportionately magnified in the mind of the individual. Whether the physical issue is real or imagined, ruminations concerning this perceived defect become pervasive and intrusive, consuming substantial mental bandwidth for extended periods each day. This excessive preoccupation not only induces severe emotional distress but also disrupts daily functioning and activities.[2] The DSM-5 places BDD within the obsessive–compulsive spectrum, distinguishing it from disorders such as anorexia nervosa.[2]
Not to be confused with body image disturbance.Body dysmorphic disorder
- Body dysmorphia
- Dysmorphic syndrome
- Dysmorphophobia
BDD is estimated to affect from 0.7% to 2.4% of the population.[2] It usually starts during adolescence and affects both men and women.[2][3] The BDD subtype muscle dysmorphia, perceiving the body as too small, affects mostly males.[4] In addition to thinking about it, the sufferer typically checks and compares the perceived flaw repetitively and can adopt unusual routines to avoid social contact that exposes it.[2] Fearing the stigma of vanity, they usually hide this preoccupation.[2] Commonly overlooked even by psychiatrists, BDD has been underdiagnosed.[2] As the disorder severely impairs quality of life due to educational and occupational dysfunction and social isolation, those experiencing BDD tend to have high rates of suicidal thoughts and may attempt suicide.[2]
Signs and symptoms[edit]
Dislike of one's appearance is common, but individuals with BDD have extreme misperceptions about their physical appearance.[5] Whereas vanity involves a quest to aggrandize the appearance, BDD is experienced as a quest to merely normalize the appearance.[2] Although delusional in about one of three cases, the appearance concern is usually non-delusional, an overvalued idea.[3]
The bodily area of focus is commonly face, skin, stomach, arms and legs, but can be nearly any part of the body.[6][7] In addition, multiple areas can be focused on simultaneously.[2] A subtype of body dysmorphic disorder is bigorexia (anorexia reverse or muscle dysphoria). In muscular dysphoria, patients perceive their body as excessively thin despite being muscular and trained.[8] Many seek dermatological treatment or cosmetic surgery, which typically does not resolve the distress.[2] On the other hand, attempts at self-treatment, as by skin picking, can create lesions where none previously existed.[2]
BDD is an obsessive–compulsive disorder[9] but involves more depression and social avoidance despite a degree of overlap with obsessive-compulsive disorder.[10][1] BDD often associates with social anxiety disorder (SAD).[10] Some experience delusions that others are covertly pointing out their flaws.[2] Cognitive testing and neuroimaging suggest both a bias toward detailed visual analysis and a tendency toward emotional hyper-arousal.[11]
Most generally, one experiencing BDD ruminates over the perceived bodily defect several hours daily or longer, uses either social avoidance or camouflaging with cosmetics or apparel, repetitively checks the appearance, compares it to that of other people, and might often seek verbal reassurances.[1][2] One might sometimes avoid mirrors, repetitively change outfits, groom excessively, or restrict eating.[6]
BDD's severity can wax and wane, and flareups tend to yield absences from school, work, or socializing, sometimes leading to protracted social isolation, with some becoming housebound for extended periods.[2] Social impairment is usually greatest, sometimes approaching avoidance of all social activities.[6] Poor concentration and motivation impair academic and occupational performance.[6] The distress of BDD tends to exceed that of either major depressive disorder or diabetes, and rates of suicidal ideation and attempts are especially high.[2]
Diagnosis[edit]
Estimates of prevalence and gender distribution have varied widely via discrepancies in diagnosis and reporting.[1] In American psychiatry, BDD gained diagnostic criteria in the DSM-IV, having been historically unrecognized, only making its first appearance in the DSM in 1987, but clinicians' knowledge of it, especially among general practitioners, is constricted.[39] Meanwhile, shame about having the bodily concern, and fear of the stigma of vanity, makes many hide even having the concern.[2][40]
Via shared symptoms, BDD is commonly misdiagnosed as social anxiety disorder, obsessive–compulsive disorder, major depressive disorder, or social phobia.[41][42] Social anxiety disorder and BDD are highly comorbid (within those with BDD, 12–68.8% also have SAD; within those with SAD, 4.8-12% also have BDD), developing similarly in patients -BDD is even classified as a subset of SAD by some researchers.[43] Correct diagnosis can depend on specialized questioning and correlation with emotional distress or social dysfunction.[44] Estimates place the Body Dysmorphic Disorder Questionnaire's sensitivity at 100% (0% false negatives) and specificity at 92.5% (7.5% false positives).[45] BDD is also comorbid with eating disorders, up to 12% comorbidity in one study. Both eating and body dysmorphic disorders are concerned with physical appearance, but eating disorders tend to focus more on weight rather than one's general appearance.[46]
BDD is classified as an obsessive–compulsive disorder in DSM-5. It is important to treat people with BDD as soon as possible because the person may have already been suffering for an extended period of time and as BDD has a high suicide rate, at 2–12 times higher than the national average.[5][46]
Treatment[edit]
Medication and psychotherapy[edit]
Anti-depressant medication, such as selective serotonin reuptake inhibitors (SSRIs), and cognitive-behavioral therapy (CBT) are considered effective.[6][47][48] SSRIs can help relieve obsessive–compulsive and delusional traits, while cognitive-behavioral therapy can help patients recognize faulty thought patterns.[6] A study was done by Dr. Sabine Wilhelm where she and her colleagues created and tested a treatment manual specializing in BDD symptoms that resulted in improved symptoms with no asymptomatic decline. Core treatment elements include Psychoeducation and Case Formulation, Cognitive Restructuring, Exposure and Ritual Prevention and Mindfulness/Perceptual Retraining.[49] Before treatment, it can help to provide psychoeducation, as with self-help books and support websites.[6]
Self-improvement[edit]
For many people with BDD, cosmetic surgery does not work to alleviate the symptoms of BDD as their opinion of their appearance is not grounded in reality. It is recommended that cosmetic surgeons and psychiatrists work together in order to screen surgery patients to see if they have BDD, as the results of the surgery could be harmful for them.[50]
History[edit]
In 1886, Enrico Morselli reported a disorder that he termed dysmorphophobia, which described the disorder as a feeling of being ugly even though there does not appear to be anything wrong with the person's appearance.[51][8] In 1980, the American Psychiatric Association recognized the disorder, while categorizing it as an atypical somatoform disorder, in the third edition of its Diagnostic and Statistical Manual of Mental Disorders (DSM).[3] Classifying it as a distinct somatoform disorder, the DSM-III's 1987 revision switched the term to body dysmorphic disorder.[3]
Published in 1994, DSM-IV defines BDD as a preoccupation with an imagined or trivial defect in appearance, a preoccupation causing social or occupational dysfunction, and not better explained as another disorder, such as anorexia nervosa.[3][52] Published in 2013, the DSM-5 shifts BDD to a new category (obsessive–compulsive spectrum), adds operational criteria (such as repetitive behaviors or intrusive thoughts), and notes the subtype muscle dysmorphia (preoccupation that one's body is too small or insufficiently muscular or lean).[53]
The term "dysmorphic" is derived from the Greek word, 'dusmorphíā' – the prefix 'dys-' meaning abnormal or apart, and 'morphḗ' meaning shape. Morselli described people who felt a subjective feeling of ugliness as people who were tormented by a physical deficit. Sigmund Freud (1856–1939), the Austrian founder of psychoanalysis, once called one of his patients, a Russian aristocrat named Sergei Pankejeff, as "Wolf Man," as he was experiencing classical symptoms of BDD. [54]