Body Dysmorphic Disorder, (BDD) is listed in the DSM-IV under somatization disorders, but clinically, it seems to have similarities to Obsessive-Compulsive Disorder (OCD).
BDD is a preoccupation with an imagined physical defect in appearance or a vastly exaggerated concern about a minimal defect. The preoccupation must cause significant impairment in the individual’s life. The individual thinks about his or her defect for at least an hour per day.
The individual’s obsessive concern most often is concerned with facial features, hair or odor. The disorder often begins in adolescence, becomes chronic and leads to a great deal of internal suffering.
The person may fear ridicule in social situations, and may consult many dermatologists or plastic surgeons and undergo painful or risky procedures to try to change the perceived defect. The medical procedures rarely produce relief. Indeed they often lead to a worsening of symptoms. BDD may limit friendships. Obsessive ruminations about appearance may make it difficult to concentrate on schoolwork.
Other behaviors that may be associated with BDD
- Frequent glancing in reflective surfaces
- Skin picking
- Avoiding mirrors
- Repeatedly measuring or palpating the defect
- Repeated requests for reassurance about the defect.
- Elaborate grooming rituals.
- Camouflaging some aspect of one’s appearance with one’s hand, a hat, or makeup.
- Repeated touching of the defect
- Avoiding social situations where the defect might be seen by others.
- Anxiety when with other people.
BDD tends to be chronic and can lead to social isolation, school dropout major depression, unnecessary surgery and even suicide.
It is often associated with social phobia and OCD, and delusional disorder. Chronic BDD can lead to major depressive disorder. If it is associated with delusions, it is reclassified as Delusional disorder, somatic subtype. Bromosis (excessive concerns about body odor) or Parasitosis (concern that one is infested by parasites) can classically be associated with delusions.
Other conditions that might be confused with BDD: Neglect caused by a parietal lobe brain lesion; anorexia nervosa, gender identity disorder.
Milder body image disturbances that do not meet criteria for BDD. :
- Benign dissatisfaction with one’s looks. This does not affect the person’s quality of life. 30-40% of Americans may have these feelings.
- Moderate disturbance with one’s body image. The person’s concerns about appearance cause some intermittent anxiety or depression.
Treatment: It is at times difficult to get an individual with BDD into psychiatric treatment because he or she may insist that the disorder has a physical origin. We prefer that the referring physician call us in advance so that we can strategize on how best to encourage the individual to accept help. Treatment often involves the use of SSRI medications (such as sertraline or fluoxetine) and cognitive-behavioral psychotherapy. In this type of psychotherapy the therapist helps the affected individual resist the compulsions associated with the BDD such as repeatedly looking in mirrors or excessive grooming (response prevention). If the individual avoids certain situations because of fear of ridicule, he or she should be encouraged to gradually and progressively face feared situations. If the individual plans to seek invasive medical/surgical treatment, the therapist should attempt to dissuade the patient or ask permission to talk with the surgeon. The therapist helps the individual to understand how some of his or her thoughts and perceptions are distorted and helps the patient replace these perceptions with more realistic ones. Family behavioral treatment can be useful, especially if the affected individual is an adolescent. Support groups if available, can help.
For more information, read The Broken Mirror or Learning to Live with Body Dysmorphic Disorder by Katharine Phillips, M.D.