Body Dysmorphic Disorder
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Body dysmorphic disorder (BDD) is a somatoform disorder in which patients have pervasive subjective feelings of ugliness about one or more aspects of their appearance despite a normal or near-normal appearance.
- Diagnostic criteria according to the DSM-5 are as follows (all must be met for diagnosis) (1):
- Preoccupation with a perceived defect in appearance. If there is a minor physical anomaly present, the concern is excessive.
- At some point, the individual has performed repetitive behaviors or mental acts in response to the appearance concerns.
- The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of function.
- The preoccupation is not accounted for by another mental disorder or meets criteria for an eating disorder.
- With muscle dysmorphia: The patient is preoccupied with the idea that his or her body build is too small or insufficiently muscular.
- By degree of insight regarding BDD beliefs:
- With good or fair insight: The individual recognizes that the BDD beliefs are definitely or probably not true or that they may or may not be true.
- With poor insight: The individual thinks that the BDD beliefs are probably true.
- With absent insight/delusional beliefs: The individual is completely convinced that the BDD beliefs are true.
- Usually begins during adolescence, mean age of onset 16.7 years; onset rare after age 40 years
- Women are affected more often than men, except for muscle dysmorphia, which occurs almost exclusively in males.
- Adolescents usually present similar to adults
- Can be present in childhood, often with refusal to attend school or plans of suicide
- Onset is usually gradual but can be abrupt.
- There is often a delay in diagnosis of 10 to 15 years after the onset of symptoms.
- Point prevalence 1.7–2.4%
- Slightly more common in United States (1)
- More common in women (2.5%) than men (2.2%)
- 6–20% in cosmetic surgery patients and in dermatologic clinic patients
Etiology and Pathophysiology
- Not well understood, likely multifactorial involving genetic, biologic, and environmental factors
- Functional MRI and EEG studies of patients with BDD note abnormalities in visual processing and frontostriatal systems, specifically left cerebral hemisphere hyperactivity. This may lead to selective recall of details and perception of distortions that do not exist.
- Dopamine D2/3 receptor availability is lower in patients with BDD compared to healthy patients.
- A cognitive behavioral model describes reinforcement-based operant conditioning and social learning pertaining to attractiveness that leads to development of maladaptive appearance-related behaviors, beliefs, and values, especially traits of perfectionism. Attractiveness is very important to patients with BDD, but they feel unattractive, leading to poor self-esteem.
- Genetic predisposition—estimated heritability of 43%; appears to be clustered with obsessive-compulsive disorder (OCD) and hoarding disorder
- Anxiety disorder or social phobia
- Pathologic skin picking
- Shyness, perfectionism, or anxious temperament
- Childhood adversity
- Childhood abuse or neglect
- Teasing or bullying, particularly appearance-based teasing
- Poor peer relationships
- Social isolation
- History of dermatologic or other physical stigmata
- Being more aesthetically sensitive than average
- Low self-esteem
- First-generation immigrant status
Commonly Associated Conditions
- Major depressive disorder (46%, most common)
- Social anxiety disorder (35%)
- Panic attacks (29%)
- OCD (17%)
- Attempted suicide (up to 25%)
- Eating disorders
- Substance-related disorders
- Bipolar disorder
- Delusional disorder