Identifying and treating body dysmorphic disorder
By Dr Patrick Treacy

 Body dysmorphic disorder (BDD) is a relatively common problem of self-image presenting in aesthetic medicine. People with BDD (around one-to-two per cent of the population) tend to preoccupy themselves with a physical feature that they consider defective. While they appear normal to most others, people with BDD are convinced they look hideous and will often avoid social contact for fear of ridicule and humiliation. As a result, they may become increasingly more isolated and even homebound. Suicide is unusually common among sufferers.

BDD was first recognised in 1886 by the Italian physician Dr Enrique Morselli, who described the disorder as a subjective feeling of ugliness terming it dysmorphophobia. He stated that patients felt miserable; they were tormented and consumed by thoughts about their imagined defect. BDD was only formally recognised as a mental disorder in 1997 when it was included in The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition The DSM IV criteria for Body Dysmorphic Disorder

• There is a preoccupation with an imagined defect of appearance or excessive concern about a slight physical anomaly. This preoccupation causes clinically important distress or impairs work, social or personal functioning.

• While the exact cause of BDD is unknown, it is likely that both biological and psychological factors play a role. The biological view is based on research, which has found that people with BDD have impaired verbal and nonverbal encoding strategies similar to that found in people with obsessive compulsive disorder (OCD). This impairment points to an organic lesion in the frontostriatal connections of the brain and may explain why both conditions respond well to high doses of selective seratonin reuptake inhibitors (SSRIs).

• The psychological view is based on the fact that people with BDD hold a demanding attitude toward their appearance. They demand perfection about how they must look and tend to judge themselves exclusively by their appearance. Their demands are unrealistic and their behaviour, often involving cosmetic procedures, can hardly ever meet their expectations. As a result they tend to rate themselves as worthless and become depressed. It has been shown that up to 60 per cent of patients with BDD also suffer from major depression.

• BDD has many features in common with OCD and has been included in the spectrum of OCD. Similarities include recurrent and intrusive thoughts about a perceived defect and activities aimed at reducing the distress caused by these thoughts.

• Thus, people with BDD preoccupy themselves with a mild or imagined defect of part of the body like hair, skin, facial areas or body proportions. They attempt to reduce their distress by frequent mirror checking and long grooming rituals but their behaviour only leads to further anxiety.

• Around three-quarters of people with BDD seek cosmetic treatments and an estimated six to15 percent of cosmetic surgery patients in the US are believed to suffer from the disorder. Unfortunately, cosmetic treatments for people with BDD are rarely beneficial and more commonly lead to exacerbation of symptoms with potential disastrous consequences. The patients tend not to be satisfied with the results and will often seek a revision procedure, or the help of another doctor. On occasion when they are satisfied, their attention will then shift to a new area.

• The most extreme complication of the disorder is death by way of suicide. In fact, people with BDD are 45 times more likely than normal to commit suicide. This represents more than twice the rate of people with major depression. It may also explain the higher than average suicide rate among cosmetic patients in general.

• BDD is under-diagnosed because patients tend to be ashamed of their problem and do not report it to their doctors. The diagnosis is also overlooked because of frequent co-morbidity with other conditions such as depression. However, a number of useful tests have been developed to identify BDD. These include: The Multidimensional Body-Self Relations Questionnaire and The Body Dysmorphic Disorder Examination. Both are self-reported measures which have been used in clinical trials, but are simply not practical for use in the routine clinical setting.

The following may help determine if a patient has BDD:

(1) Do they avoid social situations like work or school?
(2) Do they feel that this defect is causing distress or need for concealment?
(3) Do they feel this defect prevents them from developing a sexual relationship?

As suggested earlier, people with BDD tend to be dissatisfied with cosmetic treatments and will often change doctors frequently. Therefore, it is extremely important that doctors familiarise themselves with the disorder and learn to intervene in a timely and appropriate manner if seen by a GP. Referral to a psychiatrist may be necessary.
There are no large scale controlled trials to determine which is the best treatment for BDD. However, evidence from case studies and smaller trials suggest that a combination of cognitive behavioural therapy and high dose SSRIs may offer the best treatment option. The prognosis in such cases is generally good.
The commonly used SSRIs are fluoxetine (Prozac), sertaline (Lustral), and citalopram (Cipramil). The preferred treatment is to offer patients a structured programme of self-help where they learn to change their attitude toward their appearance and adopt a less demanding set of beliefs. They learn to tolerate discomfort by gradually confronting their fears without camouflage (exposure therapy) and stopping safety behaviours such as mirror checking. By changing the way a person with BDD thinks and acts, he or she may then feel less anxious and more able to cope with daily living.

Dr Patrick Treacy is Medical Director of the Ailesbury Clinic, Dublin and Regional Director of the British Association of Cosmetic Doctors

Credits
Gary K Arthur, MD, Clinical Assistant Professor, Department of Psychiatry and Behavioral Medicine, University of South Florida College of Medicine
Dr Steven Harris MSc MB BCh Member of B.A.C.D.

References
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: APA Press, 1994.
Neziroglu F, Yaryura-Tobias JA, A Review of cognitive behavioral and pharmacological treatment of body dysmorphic disorder. Behav Modif 1997 Jul; 21(3): 324-40
Nowak R, When looks can kill, New Scientist 2006 October; 2574: 18-21
Phillips KA, The Broken Mirror: Understanding and Treating Body Dysmorphic Disorder. New York: Oxford University Press, 1996
Phillips KA, Menard W, Suicidality in Body Dysmorphic Disorder: A Prospective Study, Am J Psychiatry, 2006 November; 163: 1280-1282
Sarwer DB, Wadden TA, Pertschuk MJ, Body image dissatisfaction and body dysmorphic disorder in 100 cosmetic surgery patients. Plast Reconstr Surg 1998 May; 101(6): 1644-9