Introduction
Body dysmorphic disorder (BDD) is characterized by a preoccupation with one or more perceived defects or flaws in one’s appearance. These ‘flaws’ may be physical anomalies that are not observable or appear subtle to others. It affects 2% of the general population, making it more prevalent than schizophrenia, bipolar disorder and anorexia nervosa. It is more prevalent in patients receiving cosmetic care than in the general population. (1)
The typical age of onset of BDD is in adolescence between ages 12-13 years with at least 10 years of elapsing symptoms before adequate diagnosis and treatment. The average age of those patients with BDD seeking cosmetic care is 33 years. (2)
BDD equally affects men and women, although each gender tends to focus on different types of perceived defects. Women are more likely to be preoccupied with their hips, weight, pick their skin and camouflage with makeup. Men are more likely to be preoccupied with body build, genitals, hair thinning and use a hat for camouflage. (3)
The socio-cultural value of physical appearance, which can be corrected with cosmetic surgery, can make diagnosis of BDD difficult. In a culture that values appearance, increased levels of preoccupation with body image based on an ideal body model may stimulate individuals to seek cosmetic procedures. (4) The degree of variation of appearances within a population may affect the prevalence of aesthetic dissatisfaction and prevalence of BDD. (5)
Aetiology
Childhood Maltreatment
The presence of adverse childhood experiences is a risk factor for BDD. (6) Peer abuse, bullying and teasing may be a contributing factor, present in up to 69% of patients. (7) (4) This can lead to an insecure style of interpersonal attachment manifesting in body dissatisfaction, which can be a motivation for cosmetic surgery. (5)
Sexual Trauma
Sexual trauma can result in self-disgust for sexual parts, or a part favoured by the attacker, such as hair for patients who develop BDD. (6)
Neurological Studies
Recent neurological studies suggested that people with BDD may have abnormalities in visual processing, emotional processing and transfer of visual information (8). Individuals with BDD perceive details of appearance features as defective without being able to contextualize that they are minor, relative to their whole appearance. (9)
Relationship with Obsessive-Compulsive Disorder (OCD)
There may be hereditary factors involved as the chance of BDD is four times higher in first-degree relatives of people with BDD (6) It also appears to be related to OCD. The rates of BDD-OCD comorbidity ranges from 3% to 43%, and it was postulated that some specific OCD obsessions such as symmetry obsessions, could have a relationship with BDD. (10)
Clinical Features
The diagnosis of BDD includes preoccupations with appearances with repetitive behaviours or mental acts with associated clinically significant distress and impairment in an individual’s social and occupational functioning. The presence of muscle dysmorphia and insight should be assessed, and eating disorders must be excluded. (6)
Appearance preoccupations
People with BDD may not reveal the degree of their preoccupation and distress unless asked directly because of shame about their appearance. Patients may agonise about the perceived defects for at least an hour a day but usually several hours a day, to the point they cannot function properly at work or socially. (6) In contrast, individuals with distressing or impairing preoccupation with obvious appearance flaws that are clearly noticeable at conversational distance is not diagnosed as BDD. (6)
Repetitive behaviours
At some point, the individual performs one or more repetitive, compulsive behaviours in response to the appearance concerns. This includes obsessively examining oneself in the mirror, checking by touching with his or her fingers, excessive grooming to hide or fix the perceived flaw using items such as wigs and hairpieces, hats and camouflage make-up, skin-picking to try and remove or disguise the defect, seeking reassurance from others about their appearance without satisfaction, and recurrent persistent and intrusive mental acts and thoughts, such as comparing his or her appearance with that of other people. (6) Because BDD-related repetitive behaviours can potentially be witnessed by other people, they may be a useful clue that a patient who is reluctant to divulge his or her concerns has BDD.
Clinical significance
The preoccupation must cause significant psychological distress or impairment in social or occupational functioning to make the diagnosis of BDD. (6) Patients may have difficulties with emotional or physical intimacy, manifesting in the avoidance of friends, dating, sexual contact or other social activities. Also, patients may have impairment in work or academic functioning, such as quitting jobs, dropping out of school, being late or missing work or classes, a decline in performance, or poor concentration. (11) Adolescents with BDD may present with school refusal, family discord, and social isolation. (3) These avoidance behaviours and social withdrawal reduce affective relationships and social interactions, which in turn, worsens the severity of BDD symptoms. (7)
People suffering from BDD often lack self-esteem and may be self-conscious around others. Patients may have delusions of reference, where they think that other people take special notice of the person or make fun of them because of how they look, andthey may believe they are the object of attention when they enter a room, that they are hideous, and anticipate rejection by others (6).
Patients may have comorbidities such as anxiety or depression, suicidal ideation, post-traumatic stress disorder (PTSD), eating disorders (especially women) and substance use disorder (SUD)(especially in men). (3) Those with PTSD and BDD are 6 times more likely to attempt suicide compared to BDD alone. Individuals with SUD and BDD or anorexia and BDD are 3 times more likely to attempt suicide. Compared with adults, adolescents who present with BDD have higher lifetime suicide rates and more delusional beliefs. (12)
Approximately 31-80% of individuals with BDD report that they have experienced suicidal thoughts and 25% attempt suicide. 48% eventually require psychiatric hospital admission. (3) (1) (13) For many of these individuals, BDD symptoms are the reason for their suicidality, and the rates of suicidal thoughts for individuals with BDD is 10 to 25 times higher than that of the general population. (13) (11)
Muscle dysmorphia
The muscle dysmorphia form of BDD is diagnosed if an individual has a preoccupation they lack the desired muscle mass or definition, which can include fixation on a specific muscle or muscle group. This preoccupation results in excessive weight lifting and steroid use. These individuals have higher rates of suicidality (up to 50%) and SUD, as well as poorer quality of life, than individuals with other forms of BDD. (6)
Insight
Insight predicts acceptance of and response to treatment. A clinician must assess the degree of insight regarding global body beliefs rather than about a specific body area as patients typically have multiple appearance concerns, may develop new concerns over time or experience remission of prior concerns. For example, ‘I look ugly, abnormal, or deformed’, would be how convinced the individual is that his/her belief regarding the appearance of the disliked body parts is true.
Less than 5% of patients have ‘good or fair insight’ and will respond favourably to reassurance for a short period or be distractible from their preoccupation. Those ‘with poor insight’ require constant reassurance or must check frequently on their appearance, but will have moments of insight. One-third of patients with BDD have ‘absent insight’ or ‘with delusional beliefs’. In this case, the individual is convinced beyond a doubt of the imperfection, will not respond to reassurance, or corrective surgery (6). Such patients may be reluctant to accept the diagnosis or psychological treatment of BDD. Poorer insight is significantly associated with more severe BDD symptoms. Despite absent insight or delusional beliefs, these individuals are still diagnosed with BDD, not as a psychotic disorder. (6)
BDD and Cosmetic Surgery
The perceived defects can be multiple and often serial, for example, once one perceived defect has lessened, another defect will become the focus of the patient’s attention. Typical problems might be hair thinning, acne, large pores, the nose being too large or bent, wrinkles on the skin, features not being in proportion; or features being too masculine (or feminine). Complaints about the shape of the abdomen and breast are associated with body weight, shape and changes in pregnancy.
People with BDD may present to general practitioners, dermatologists, cosmetic, ear, nose and throat, maxillary facial surgeons, orthodontists, gynaecologists or urologists with a desire to improve their defect. They present to mental health services less commonly, and usually only when there are additional problems such as depression, being housebound, or a risk of suicide. (11)
BDD is one of the commonest psychiatric conditions found in patients seeking cosmetic surgery, hoping to improve the appearance of their perceived flaw. (2) (7) (14) Worldwide studies suggest that between 5 to 15% of patients who present for cosmetic treatment have BDD. (14) Individuals with BDD are five times more likely to have a history of cosmetic surgery than the normal population. (1) Body contouring surgery is most frequently sought, and in a cohort of Brazilian patients undergoing abdominoplasty, 57% of patients had BDD symptoms (5). Requests for rhinoplasty are associated with ethnicity and requests for facial cosmetic procedures were associated with concerns about aging. (5) Men are as likely as women to seek non-psychiatric medical and surgical treatment and have cosmetic surgery. (3)
There is little evidence to suggest that patients with BDD improve in psychological functioning following cosmetic surgery, rather, greater than 90% report no improvement or worsening in their BDD symptoms. (15) At best, a patient may be satisfied with some procedures when change is unambiguous, for example breast augmentation or labiaplasty. (16) BDD patients are more likely to be dissatisfied with the results of dermatological treatments, which can make preoccupation with the perceived defect and handicap worse, causing difficulties in engagement with treatment because a further procedure would be needed to correct the current defect. Individuals with BDD are believed to be more likely to bring medical-legal proceedings against their surgeon when dissatisfied with their results, as well as threaten or commit acts of violence against the treating clinician. (17)
For these reasons, BDD may be considered a contraindication to surgery and cosmetic surgeons are encouraged to assess for symptoms of BDD in their patients both before and after treatment and be prepared to refer patients to a mental health professional. (18)
Tests
Clinicians must ascertain that the patient is preoccupied with one or more non-existent or slight defects in their physical. To assess this, ask whether the patient is worried about their appearance or unhappy with how they look. Do not ask a patient whether they are preoccupied ‘with minimal or non-existent flaws’ as usually you will miss the diagnosis because patients typically have poor or absent insight, not realizing that the flaws they perceive are not visible or are quite minimal. Ask patients how noticeable or abnormal they believe their defect is on a scale of one to 10. If there is substantial difference between the score of the doctor and that of the patient, then this might start a discussion on an alternative understanding of the problem. A patient’s self-portrait may also help the doctor understand the perceived defect from the patient’s viewpoint. (11)
Validated screening tests include the Body Dysmorphic Disorder Questionnaire, which has high sensitivity (100%) and specificity (89-93%) for the BDD diagnosis. Diagnostic tests include the Structured Clinical Interview for DSM-IV, BDD Diagnostic Module, and Body Dysmorphic Disorder Examination. For patients who have already been diagnosed with BDD, severity can be measured with the BDD Yale-Brown Obsessive Compulsive Scale. (6) Insight can be measured using the Brown Assessment of Beliefs Scale. (6)
Treatment
Considerable tact and frequent visits are often needed to gain the patient's trust before introducing the fact the problem is a psychiatric illness. Sufferers are often reluctant to seek psychiatric help. If there is a visible difference that can be viewed up close and by raising your aesthetic standards, such as mild acne scarring, then it is important to indicate to the individual that you, as a clinician, can see this. Some patients are not worried about the evaluation of others but are more concerned with feeling average or asymmetrical. (11)
Referrals may include a psycho-dermatology clinic for skin problems or a national specialist service for BDD. A referral to such units may be more acceptable to patients because they will have more time to feel understood. (19)
Psychological Treatment
Cognitive behavioural therapy (CBT) specific for BDD follows a protocol over 16-24 sessions. CBT can encourage self-esteem, change distorted thoughts and form coping strategies. Studies have shown that CBT is more effective than oral medication at 12 weeks of therapy for BDD even with delusional beliefs or depression. (20) The vital aspect of CBT is to continue to engage the patient and fine-tune the agenda to reducing preoccupation, distress, and interference of the condition in the patient’s life. The emphasis is to build another understanding of the problem and lessen self-focused attention and ruminating. Patients are directed through graded exposure or behavioural experiments to test out their fears. Behavioural modification therapy can help by stopping or reducing compulsive behaviours such as skin picking. Inpatient or residential unit services with intensive CBT are appropriate for a small number of people in whom one or more trials of therapy and drugs as an outpatient have been ineffective. Recommend further reading and websites for patients with BDD. (11)
Medical Treatment
Antidepressant medication (AM), especially selective serotonin reuptake inhibitor (SSRIs) such as fluoxetine is effective and recommended for moderate to severe BDD (21). SSRI’s can be an adjunct to CBT. (20) Patients with moderate or severe body BDD may respond to an SSRI at the maximum tolerated dose for at least three months to determine treatment response. If one SSRI is unhelpful, an alternative SSRI or a potent serotonin reuptake inhibitor such as clomipramine may be helpful. As in patients with obsessive-compulsive disorders, there may be a high rate of relapse when a SSRI is stopped. (21)
Delusional BDD and nondelusional BDD exist in a spectrum. Importantly, delusional BDD may respond as well to SSRI monotherapy as nondelusional BDD does, with majority of patients in both groups experiencing significant improvement with an SRI alone. Studies have found that level of insight improves with SRI treatment. There is no evidence for the benefit of antipsychotics to augment a SSRI in BDD. (22)
When immediate risk is not considered the priority, the doctor needs to continue to engage the patient. A specialist can consider appropriate treatment of the defect such as a topical retinoid or combination agents for acne or mild acne scarring.
Prognosis
BDD is a chronic disorder that persists for many years if left untreated (2). It is important to emphasise to patients that BDD is a recognised problem for which there is successful treatment, although this will re