Body Dysmorphic Disorder
New York, NY (August 29, 2000)
What is body dysmorphic disorder (BDD)?
BDD, previously known as dysmorphophobia, is a psychiatric disorder characterized by an uncontrollable preoccupation with an imagined or slight defect in appearance. If a slight physical anomaly is present, the person's concern is markedly excessive, and the preoccupation causes significant distress or impairment in social, occupational, or other important areas of functioning. Although there is a growing awareness of this disorder, BDD appears to be underdiagnosed and may be more common than previously believed.
What are some characteristics of BDD?
Individuals with BDD are obsessed with the idea that they look deformed and spend hours each day thinking about it. (The mean time is 3 to 8 hours each day.) They also exhibit compulsive repetitive behaviors such as camouflaging the area of concern (e.g. always wearing hats, multiple layers of clothing, or excessive amounts of makeup); comparing themselves with others; checking their appearance in the mirror; questioning others about their appearance and seeking reassurance. Individuals may go through these behaviors 20, 50, or 100 times per day.
Feelings of low self-esteem, shame, and fear of rejection are common, and current data report that more than half of those with BDD also have major depression. Insight is variable-- ranging from good to absent--and may change at different periods of time.
What are the most common areas of preoccupation?
The skin (complaints of blemishes, scarring, redness...), hair (thinning, uneven, too curly, too straight...), and nose (too large, too small, too long, too short...). However, any area of the body can be the focus, and most persons with BDD have concerns about more than one area.
How does BDD affect one's day-to-day life?
BDD is a distressing and disabling disease. Much time and energy is spent on scrutinizing and hiding "flaws." Most individuals have some degree of social, as well as occupational and academic impairment. Although some individuals appear to be functioning well, they may not be realizing their full potential. Others may be housebound and suicidal. In some cases, severe bodily harm can occur; patients may want to remove a mark on their face and will scrape their skin to the depth of major blood vessels, which requires emergency treatment. Others may try to perform their own surgery.
Are patients with BDD good candidates for aesthetic plastic surgery?
Many individuals with BDD will seek nonpsychiatric treatment, and plastic surgeons may be consulted. Although prospective studies are limited, it appears that most patients with BDD are dissatisfied with their result if surgery is performed. Distress about their appearance may actually increase or preoccupation with another area of the body may occur. Multiple procedures with multiple doctors may be sought in a search for a solution to a physical complaint, which is psychiatric in origin.
How is BDD diagnosed?
Diagnosis is challenging because patients are embarrassed or shameful and often try to hide their symptoms. Additionally, many patients who seek treatment for minimal physical imperfections do not have BDD and, in fact, may be excellent candidates for cosmetic surgery. As with all prospective patients, plastic surgeons conduct a thorough interview to determine if aesthetic plastic surgery is appropriate for that individual. General discussion includes the patient's motivation for surgery as well as expectations, which should be realistic.
Plastic surgeons can be alerted to the possibility of an underlying psychiatric disorder by the following: body image distortions that are not reality based; impaired work or social functioning due to the physical complaint; a long history of multiple procedures to correct the slight defect; general signs of depression or anxiety; the coexistence of social phobia or obsessive-compulsive disorder (OCD). Direct questioning regarding the characteristic behaviors (i.e. skin picking, mirror checking, camouflaging, etc.) may be necessary. If BDD is suspected, plastic surgeons may require that patients undergo psychiatric evaluation before pursuing a surgical solution to their problem. Ultimately, the surgeon will use his or her best judgment, perhaps in consultation with a mental health professional, to determine whether or not a particular patient can reasonably be expected to benefit from cosmetic surgery.
What treatments are available?
Those who have BDD often respond to psychiatric treatment and should speak to their primary doctor or a psychiatrist for treatment options. Success has been reported with cognitive behavior therapy and a class of medications called selective serotonin reuptake inhibitors (SSRIs), such as Prozac, Paxil, and Zoloft. However, controlled clinical studies are necessary to more clearly define the best treatment approaches for this disorder.
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