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 is unknown.
- Predisposing factors thought to include:
- 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.
- 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
- Subtype of body dysmorphic disorder (BDD)
- Preoccupied with idea that body build is too small or insufficiently muscular
- Commonly seen in boys
- Usually associated with steroid abuse
- Major depression
- Social anxiety disorder
- Personality disorders
- Eating disorders
- Substance use disorders
- 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
- 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:
- Metacognitive therapy
- Address co-morbidities.
- Pharmacological interventions:
- Selective serotonin reuptake inhibitors (SSRIs; fluoxetine)
- Psychological interventions:
- 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.
- Generalized anxiety disorder: marked by chronic, multiple worries that are irrational and uncontrollable. Associated with fatigue, low concentration, restlessness, irritability, and sleep disturbance. Symptoms last for more than 6 months and cause significant decline in functioning. Treatment includes psychotherapy and medications (e.g., SSRI or serotonin-norepinephrine reuptake inhibitor (SNRI) antidepressants).
- 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 for performance-only subtype.
- 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 medication.
- 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 (CBT) and patient hospitalization for optimization of nutritional deficiencies.
- 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/
- 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/
- 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/
- 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/
- 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/
- Gunstad J, Phillips KA. (2003). Axis I comorbidity in body dysmorphic disorder. Compr Psychiatry. https://pubmed.ncbi.nlm.nih.gov/12923704/