Body Dysmorphic Disorder

Body dysmorphic disorder (BDD) is a psychiatric disorder characterized by a patient’s preoccupation with minor or imagined flaws in their physical appearance. The obsession over the perceived defect leads to compulsive behaviors to cover it up, either with cosmetic therapy or social avoidance. These patients have a high incidence of comorbid depression and anxiety and may benefit from psychotherapy Psychotherapy Psychotherapy is interpersonal treatment based on the understanding of psychological principles and mechanisms of mental disease. The treatment approach is often individualized, depending on the psychiatric condition(s) or circumstance. Psychotherapy, along with selective serotonin reuptake inhibitors Serotonin Reuptake Inhibitors Antidepressants encompass several drug classes and are used to treat individuals with depression, anxiety, and psychiatric conditions, as well as those with chronic pain and symptoms of menopause. Antidepressants include selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), and many other drugs in a class of their own. Serotonin Reuptake Inhibitors and Similar Antidepressant Medications (SSRIs).

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Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

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Epidemiology and Etiology

  • Worldwide prevalence: 2%–4%
  • Girls > boys
  • Onset typically in adolescence (65% by the age of 18 years)
  • 90% of patients have comorbid depression.
  • 70% have comorbid anxiety.
  • 30% have comorbid psychotic disorder.
  • Incidence is highest in dermatologic and cosmetic surgery patients.

Etiology

  • Etiology is unknown.
  • Predisposing factors thought to include:
    • Genetics Genetics Genetics is the study of genes and their functions and behaviors. Basic Terms of Genetics: 43% heritability noted in monozygotic twins
    • Frontal lobe dysfunction → deficits in executive function → focus on specific details of body rather than entirety of appearance
    • History of neglect or abuse
  • Some studies suggest genetic predisposition along with OCD OCD Obsessive-compulsive disorder (OCD) is a condition characterized by obsessions (recurring and intrusive thoughts, urges, or images) and/or compulsions (repetitive actions the person is compelled to perform) that are time-consuming and associated with functional impairment. Obsessive-compulsive Disorder (OCD).

Clinical Presentation

General

  • Patients don’t usually disclose the preoccupation.
  • Patients have varying degrees of insight into symptoms and must be asked specifically.
  • Often present to dermatology or plastic surgery for correction of perceived imperfection
  • May present with:
    • Social anxiety and avoidance
    • Emotional distress
    • Poor psychosocial functioning and quality of life
    • Suicidal ideation and behavior:
      • 4 times more likely to develop ideas
      • 2 times more likely to carry it out
    • Aggressive behavior

Muscle dysmorphia

  • Subtype of body dysmorphic disorder (BDD)
  • Preoccupied with idea that body build is too small or insufficiently muscular
  • Commonly seen in men
  • Usually associated with steroid abuse

Comorbidities

  • Major depression
  • Social anxiety disorder Social anxiety disorder Social anxiety disorder, or social phobia, is a psychiatric illness marked by fear and avoidance of social interactions due to concerns about embarrassment. The disorder usually occurs in more than one social situation for more than 6 months and leads to a significant decline in function. Social Anxiety Disorder
  • Personality disorders 
  • OCD OCD Obsessive-compulsive disorder (OCD) is a condition characterized by obsessions (recurring and intrusive thoughts, urges, or images) and/or compulsions (repetitive actions the person is compelled to perform) that are time-consuming and associated with functional impairment. Obsessive-compulsive Disorder (OCD)
  • Eating disorders
  • Substance use disorders

Diagnosis

Patients exhibit:

  • Preoccupation with 1 or more perceived defects or flaws in physical appearance that are not observable or appear slight to others:
    • Thought is difficult to resist or control.
    • Occurs for an average of 3–8 hours/day
  • Repetitive behaviors or mental acts in response to concern with appearance:
    • Comparing features with those of others
    • Mirror checking
    • Excessive grooming
    • Seeking reassurance from others
    • Camouflaging
  • Clinically significant distress or impairment in social, occupational, or other areas of functioning due to preoccupation/compulsion
  • Meeting the diagnostic criteria for eating disorders supersedes a diagnosis of BDD.

Management and Prognosis

  • Psychoeducation is important, as many patients lack insight into the condition.
  • Treatment includes psychological and pharmacological interventions:
    • Psychological interventions:
      • CBT
      • Metacognitive therapy
      • Address co-morbidities.
    • Pharmacological interventions:
      • Selective serotonin reuptake inhibitors Serotonin Reuptake Inhibitors Antidepressants encompass several drug classes and are used to treat individuals with depression, anxiety, and psychiatric conditions, as well as those with chronic pain and symptoms of menopause. Antidepressants include selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), and many other drugs in a class of their own. Serotonin Reuptake Inhibitors and Similar Antidepressant Medications (SSRIs; fluoxetine)
      • Clomipramine

Prognosis

  • Chronic illness
  • Response to treatment requires ≤ 16 weeks of therapy.
  • Response rate of 50%–80% with pharmacological treatment
  • Relapses are common; maintenance SSRI therapy recommended.

Differential Diagnosis

  • Generalized anxiety disorder Generalized anxiety disorder Generalized anxiety disorder (GAD) is a common mental condition defined by excessive, uncontrollable worrying causing distress and occurring frequently for at least 6 months. Generalized anxiety disorder is more common in women. Clinical presentation includes fatigue, low concentration, restlessness, irritability, and sleep disturbance. Generalized Anxiety Disorder: marked by chronic, multiple worries that are irrational and uncontrollable. Associated with fatigue, low concentration, restlessness, irritability, and sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep disturbance. Symptoms last for more than 6 months and cause significant decline in functioning. Treatment includes psychotherapy Psychotherapy Psychotherapy is interpersonal treatment based on the understanding of psychological principles and mechanisms of mental disease. The treatment approach is often individualized, depending on the psychiatric condition(s) or circumstance. Psychotherapy and medications (e.g., SSRI or serotonin-norepinephrine reuptake inhibitor (SNRI) antidepressants). 
  • Social anxiety disorder Social anxiety disorder Social anxiety disorder, or social phobia, is a psychiatric illness marked by fear and avoidance of social interactions due to concerns about embarrassment. The disorder usually occurs in more than one social situation for more than 6 months and leads to a significant decline in function. Social Anxiety Disorder: disorder or social phobia marked by fear and avoidance of social interactions due to concerns about embarrassment. Usually occurs in more than 1 social situation for more than 6 months and leads to a significant decline in function. Performance subtype occurs only in performance-related situations (e.g., giving a speech in front of others). Treatment includes CBT, antidepressants (SSRI, SNRI), and beta-blockers or benzodiazepines Benzodiazepines Benzodiazepines work on the gamma-aminobutyric acid type A (GABAA) receptor to produce inhibitory effects on the CNS. Benzodiazepines do not mimic GABA, the main inhibitory neurotransmitter in humans, but instead potentiate GABA activity. Benzodiazepines for performance-only subtype. 
  • OCD OCD Obsessive-compulsive disorder (OCD) is a condition characterized by obsessions (recurring and intrusive thoughts, urges, or images) and/or compulsions (repetitive actions the person is compelled to perform) that are time-consuming and associated with functional impairment. Obsessive-compulsive Disorder (OCD): characterized by obsessions (recurring senseless and intrusive thoughts, feelings, or sensations) that cause severe distress. Obsessions are neutralized partly by compulsions (repetitive actions), which are time-consuming and affect patient quality of life. Patients may experience either obsessions alone or a combination of obsessions and compulsions. Treatment is monotherapy with antidepressants, which may be augmented by CBT and antipsychotic Antipsychotic Antipsychotics, also called neuroleptics, are used to treat psychotic disorders and alleviate agitation, mania, and aggression. Antipsychotics are notable for their use in treating schizophrenia and bipolar disorder and are divided into 1st-generation antipsychotics (FGAs) and atypical or 2nd-generation antipsychotics. First-Generation Antipsychotics medication.
  • Anorexia nervosa Anorexia Nervosa Anorexia nervosa is an eating disorder marked by self-imposed starvation and inappropriate dietary habits due to a morbid fear of weight gain and disturbed perception of body shape and weight. Patients have strikingly low BMI and diverse physiological and psychological complications. Anorexia Nervosa: eating disorder marked by self-imposed starvation and inappropriate dietary habits due to morbid fear of weight gain and disturbed perception of body shape and weight. Patients have strikingly low body weight (≤ 18.5 kg) and diverse physiological and psychological complications. Most commonly seen in adolescent girls. Treatment mainly consists of psychotherapy Psychotherapy Psychotherapy is interpersonal treatment based on the understanding of psychological principles and mechanisms of mental disease. The treatment approach is often individualized, depending on the psychiatric condition(s) or circumstance. Psychotherapy (CBT) and patient hospitalization for optimization of nutritional deficiencies.

References

  1. Veale D, Gledhill LJ, Christodoulou P, Hodsoll J. (2016). Body dysmorphic disorder in different settings: A systematic review and estimated weighted prevalence. Body Image. https://pubmed.ncbi.nlm.nih.gov/27498379/
  2. Enander J, Ivanov VZ, Mataix-Cols D, Kuja-Halkola R, Ljótsson B, Lundström S, Pérez-Vigil A, Monzani B, Lichtenstein P, Rück C. (2018). Prevalence and heritability of body dysmorphic symptoms in adolescents and young adults: A population-based nationwide twin study. Psychol Med. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6236441/
  3. Grant JE, Kim SW, Crow SJ. (2001). Prevalence and clinical features of body dysmorphic disorder in adolescent and adult psychiatric inpatients. J Clin Psychiatry. https://pubmed.ncbi.nlm.nih.gov/11488361/
  4. Phillipou A, Rossell SL, Wilding HE, Castle DJ. (2016). Randomised controlled trials of psychological & pharmacological treatments for body dysmorphic disorder: A systematic review. Psychiatry Res. https://pubmed.ncbi.nlm.nih.gov/27544783/
  5. Phillips KA, Keshaviah A, Dougherty DD, Stout RL, Menard W, Wilhelm S. (2016). Pharmacotherapy relapse prevention in body dysmorphic disorder: A double-blind, placebo-controlled trial. Am J Psychiatry. https://pubmed.ncbi.nlm.nih.gov/27056606/
  6. Gunstad J, Phillips KA. (2003). Axis I comorbidity in body dysmorphic disorder. Compr Psychiatry. https://pubmed.ncbi.nlm.nih.gov/12923704/

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