- Body dysmorphic disorder
Body Dysmorphic Disorder Classification and external resources ICD-10 F45.2 ICD-9 300.7 DiseasesDB 33723 eMedicine med/3124
Body Dysmorphic Disorder (BDD, also body dysmorphia, dysmorphic syndrome; originally dysmorphophobia) is a type of mental illness, a somatoform disorder, wherein the affected person is exclusively concerned with body image, manifested as excessive concern about and preoccupation with a perceived defect of his or her physical features.  The man or woman complains of a defect in either one feature or several features of his or her body; or vaguely complains about his or her general appearance, which causes psychological distress that impairs either occupational or social functioning, or both. Occasionally, BDD occurs to the degree of causing severe emotional depression and anxiety, and the possible development of other anxiety disorders, social withdrawal, or social isolation.
The causes of Body Dysmorphic Disorder are different for each person, usually a combination of biological, psychological, and environmental factors from either the person's past or present life. Furthermore, mental and physical abuse, and emotional neglect, also are life-experiences that can contribute to a person developing BDD. The onset of the symptoms of a mentally unhealthy preoccupation with body image occurs either in adolescence or in early adulthood, whence begins self-criticism of the personal appearance, from which develop atypical aesthetic-standards derived from the internal perceptual discrepancy between the person's ‘actual self’ and the ‘idea self’. The symptoms of body dysmorphia include psychological depression, social phobia, and obsessive compulsive disorder.
As a form of mental illness, BDD is linked to a diminished quality of life, can be co-morbid with major depressive disorder and social phobia (chronic social anxiety); features a suicidal ideation rate of 80 percent, in extreme cases linked with dissociation, and thus can be considered a factor in the person's attempting suicide. BDD can be treated with either psychotherapy or psychotropic medication, or both; moreover, cognitive behavioural therapy (CBT) and selective serotonin reuptake inhibitors (SSRIs) are effective treatments. Although originally a mental-illness diagnosis usually applied to women, Body Dysmorphic Disorder occurs equally among men and women, and occasionally in children and older adults. Approximately one-to-two percent (1–2%) of the world's population might meet the diagnostic criteria for a diagnosis of Body Dysmorphic Disorder. 
- 1 Overview
- 2 Symptoms
- 3 Causes
- 4 Diagnoses
- 5 Treatment
- 6 Prognosis
- 7 Epidemiology
- 8 History
- 9 See also
- 10 References
- 11 Further reading
- 12 External links
The Diagnostic and Statistical Manual of Mental Disorders defines body dysmorphic disorder as a somatoform disorder marked by a preoccupation with an imagined or trivial defect in appearance that causes clinically significant distress or impairment in social, occupational or other important areas of functioning. 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 of which those suffering from BDD will feel critical 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 may generally be 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. More extreme cases may cause a person to develop love-shyness, a chronic avoidance of all intimate relationships. They can become secretive and reluctant to seek help because they fear that seeking help will force them to confront their insecurity. They feel too embarrassed and unwilling to accept that others will tell the sufferer that he or she is suffering from a disorder. The sufferer believes that fixing the "deformity" is the only goal, and that if there is a disorder, it was caused by the deformity. In extreme cases, patients report that they would rather suffer from their symptoms than be 'convinced' into believing that they have no deformity. It has been suggested that fewer men seek help for the disorder than women.
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.
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. Suicidal ideation is also found in around 80% of people with BDD. There has also been a suggested link between undiagnosed BDD and a higher-than-average suicide rate among people who have undergone cosmetic surgery.
There are many common symptoms and behaviors associated with BDD. Often these symptoms and behaviors 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.
Common symptoms of BDD include:
- Obsessive thoughts about (a) perceived appearance defect(s).
- Obsessive and compulsive behaviors related to (a) perceived appearance defect(s) (see section below).
- Major depressive disorder symptoms.
- Delusional thoughts and beliefs related to (a) perceived appearance defect(s).
- Social and family withdrawal, social phobia, loneliness and self-imposed social isolation.
- Suicidal ideation.
- Anxiety; possible panic attacks.
- Chronic low self-esteem.
- 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.
- Dependent personality: dependence on others, such as a partner, friend or family.
- Inability to work or an inability to focus at work due to preoccupation with appearance.
- Problems initiating and maintaining relationships (both intimate relationships and friendships).
- Alcohol and/or drug abuse (often an attempt to self-medicate).
- 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 observing a mirror or reflective surface.
- Perfectionism (undergoing cosmetic surgery and behaviors such as excessive moisturizing and exercising with the aim to achieve an ideal body type and reduce anxiety).
- 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 defective.
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.
- Excessive grooming behaviors: skin-picking, combing hair, plucking eyebrows, shaving, etc.
- 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, or same sex if homosexual.
- Seeking reassurance from loved ones.
- Excessive dieting or exercising, working on outside appearance.
- 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.
- Obsession with plastic surgery or dermatological procedures, often with little satisfactory results (in the perception of the patient).
- In extreme cases, patients have attempted to perform plastic surgery on themselves, including liposuction and various implants with disastrous results.
- Excessive enema use (if obesity is the concern).
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%)
- Weight (55%)
- Nose (37%)
- Toes (36%)
- Abdomen (22%)
- Breasts/chest/nipples (21%)
- Eyes (20%)
- Thighs (20%)
- Teeth (20%)
- Legs (overall) (18%)
- Body build/bone structure (1.5%)
- Facial features (general) (1.4%)
- Face size/shape (20%)
- 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%)
- Ankles (2%)
- Facial muscles (1%)
People with BDD often have more than one area of concern.
There is comorbidity with other psychological disorders, which often results in misdiagnoses by medical individuals. New Research indicates that around 76% of people with BDD will experience major depressive disorder at some point in their lives, significantly higher than the 10–20% expected in the general population. Nearly 36% of people with BDD will also produce agoraphobia and around 32% are also affected by obsessive–compulsive disorder. The most common disorders found in individuals with BDD are avoidant personality disorder, social phobia, social anxiety disorder, borderline personality disorder and dependent personality disorder, which conforms to the introverted, shy and neurotic traits usually found in BDD sufferers.
BDD usually develops in teenagers, a time when individuals are most concerned about the way they look to others. However, many patients suffer for years before seeking help. There is no single cause of body dysmorphic disorder; research shows that a number of factors may be involved and that they can occur in combination. BDD can be associated with eating disorders, such as compulsive overeating, anorexia nervosa or bulimia, or it can be more of a phobia, associated instead with social phobia or social anxiety disorder.
- Obsessive–compulsive disorder.
BDD can often occur with OCD, where the patient practices unmanageable habitual 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. Other phobias like social phobia or social anxiety disorder may also be co-occurring.
- 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, 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. Around 60% of people with BDD report frequent or chronic childhood teasing.
- Parenting style:
Similarly to teasing, parenting style may contribute to BDD onset; for example, parents who either place excessive emphasis on aesthetic appearance, or disregard it altogether, may act as a trigger in the genetically-predisposed.
- 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.
It has been theorized that media pressure may contribute to BDD 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.
Certain personality traits may make someone more susceptible to developing BDD. Personality traits which have been proposed as contributing factors include: 
- Introversion / shyness
- Sensitivity to rejection or criticism
- Avoidant personality
- Schizoid personality
- Social phobia
- Social anxiety disorder
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.
According to the DSM IV to be diagnosed with BDD a person must fulfill the following criteria:
- "Preoccupation with an imagined or slight 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)."
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. 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.
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.
BDD is also often misdiagnosed because its symptoms can mimic that of major depressive disorder or social phobia. 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.
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.
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.
A combined approach of Cognitive Behaviour Therapy (CBT) and anti-depressants is more effective than either alone. The dose of a given anti-depressant is usually more effective when it exceeds the maximum recommended doses that are given for Obsessive Compulsive Disorder (OCD) or a major Depressive episode.
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.  Treatment can improve the outcome of the illness for most people. However, 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.
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. 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.
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. It has since been changed from "Dysmorphophobia" to "Body dysmorphic disorder" because the original implies a phobia of people, not a reluctance to interact socially because of poor body image.
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.
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- TV documentary by former BDD sufferer John Furse
- Mark Wheeler, U.C.L.A."People with body-image disorders process 'big picture' visual information abnormally" 
- BBC Headroom: Understanding BDD
- BDDCentral: BDD Website and Support Forum
- Massachusetts General Hospital/Harvard Medical School, Body Dysmorphic Disorder Clinic and Research Center
-  On-line Support Group for Body dysmorphic disorder sufferers.
- Social Anxiety Anonymous International Nonprofit that provides free support groups, including for Body Dysmorphic Disorder sufferers
- Katharine Phillips, MD—The Body Image Program at Rhode Island Hospital/Brown University
- VideoJug—Body dysmorphic disorder Information
- UCLA Body Dysmorphic Disorder Research
- Support Group Providers for / Body dysmorphic disorder at the Open Directory Project
- OCD-UK—Information for BDD and OCD sufferers
- OCD Action UK
- German Body Dysmorphic Disorder Website
- BDD advice and bdd support, Body Dysmorphic Disorder help and advice
- Body Dysmorphic Disorder—FAQ, Dr David Veale
- BBC Horizon: Complete obsession: Body dysmorphia 2000
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