130 Body Dysmorphic Disorder (300.7)

DSM-IV-TR criteria

A. Preoccupation with an imagined defect in appearance. If slight physical abnormality is present, the person’s concern is markedly excessive.

B. The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

C. The preoccupation is not better accounted for by another mental disorder (e.g., dissatisfaction with body shape and size in Anorexia Nervosa).

Associated features

The preoccupations associated with body dysmorphic disorder (BDD) are commonly described as being repetitive, excessive, obsessive, compulsive, ritualized, distressing, impairing, time-consuming, and somewhat less often, delusional. Symptoms usually appear suddenly, with onset during times of extreme psychosocial stress. The similarities in descriptions of preoccupation frequently cause a misdiagnosis of obsessive-compulsive disorder (OCD), however, the comorbidity of OCD and BDD is relatively common. Other common comorbidities include, but not limited to; mood disorders (major depressive disorder), anxiety disorders (social phobia), substance use, eating disorders (anorexia nervosa), and personality disorders (borderline personality disorder). Examples of preoccupations include behaviors that seek to examine, improve, or hide perceived defects leading to time consuming functional impairments. Activities associated with preoccupations include obsessions in: grooming; mirror checking, hair brushing, hair styling, hair cutting, shaving, washing, and application of makeup. Camouflaging: wearing wigs, hats, make-up, sunglasses, extra clothing and changing body position to hide perceived defect. Medical procedures: numerous dermatological visits, and multiple cosmetic surgeries. Need for reassurance: mirror checking, asking others opinion, and excessive comparison to other people. Diet and exercise: excessive exercise, muscle dysmorphia, steroid usage; excessive diet, anorexia nervosa, and bulimia nervosa (eating disorders). The most common preoccupations of the body focus primarily on the skin, hair, and nose. People diagnosed with BDD typically have poor self-image/esteem, express shame in appearance, feel ugly, unlovable, and have a strong fear of rejection. Suicide ideation, attempts, and completion are significantly high in comparison to other mental disorders; however, the studies are few and only preliminary. Reasons for results suggest that suicidal risk is higher in patients with BDD. High suicidal risks are due to high rates of psychiatric hospitalization, comorbidity prevalence, being single and divorced, low self-esteem, poor social support, and having high levels of anxiety, depression, and hostility.

Child vs. adult presentation

Most research suggests that the onset of BDD begins in early adolescents, although, little research has been done regarding definite onset. The role of body image during pubertal change increases body focus and dissatisfaction. Adolescents typically present more often with body shape and weight concerns related to distress, as opposed to adult presentation of dissatisfaction of specific body parts (i.e., face and hair).

Gender and cultural differences in presentation

Most research suggest BDD in non-discriminative across gender lines. Some research suggests females are more likely to present with associated features resembling weight and shape concerns, eating disorders, and depressive disorders. Sociocultural influences include appearance related pressures. Socially constructed conceptions of perfection and/or beauty portrayed through the media affect both genders without bias. BDD exists in many cultures around the world. The areas having the most research conducted include the United States, Italy, and the United Kingdom. Studies pertaining to prevalence rates cross-cultures have been insignificant in number; the studies done suggest prevalence rates to be very similar.

Epidemiology

Several sources of research agree prevalence rates in the general population vary from 1% – 2%. Prevalence rates tend to increase in clinical settings. Prevalence rates in the medical population of dermatology increase to 11.9%, and in the cosmetic surgery population, an increase of 2% – 7%. People suffering with BDD typically present to cosmetic surgeons for correction of perceived bodily flaw, and inevitably receive no satisfaction or relief from the disorder.

Etiology

The onset of BDD generally begins around the pubertal time of adolescents. The disorder is more commonly chronic and unremitting than it is not. The course of this disorder follows a continuous lifetime course, in that; it is very unlikely for full remission to occur with treatment. Suicidal ideation is higher for this disorder than other mental disorders.

Empirically supported treatments

• Serotonin deregulation seems to be common among patients with BDD. Selective serotonin reuptake inhibitor (SSRI) (i.e., fluoxetine hydrochloride) drugs have been empirically proven to decrease the symptoms associated with BDD. Another empirically supported approach is cognitive behavioral therapy (CBT). A combination of SSRI and CBT is the common approach to BDD.
• Behavioral and/or cognitive-behavioral techniques are typically used to change abnormal activities like avoidance behavior, reassurance seeking, checking, and excessive grooming. For example, exposure in vivo can be used to help people with BDD become more comfortable exposing themselves to social situations.

Links:

• Article about Body Dysmorphic Disorder in American population (Need UCO login and password to access article).

Proposed DMS-5 Changes

The work group is recommending that this disorder be reclassified from Somatoform Disorders to Anxiety and Obsessive-Compulsive Spectrum Disorders

A. Preoccupation with a perceived defect(s) or flaw(s) in physical appearance that is not observable or appears slight to others.
B. At some point during the course of the disorder, the person has performed repetitive behaviors (e.g., mirror checking, excessive grooming, skin picking, or reassurance seeking) or mental acts (e.g., comparing their appearance with that of others) in response to the appearance concerns.
C. The preoccupation causes clinically significant distress (for example, depressed mood, anxiety, shame) or impairment in social, occupational, or other important areas of functioning (for example, school, relationships, household).

D. The appearance preoccupations are not restricted to concerns with body fat or weight in an eating disorder.

Specify if:

Muscle dysmorphia form of body dysmorphic disorder (the belief that one’s body build is too small or is insufficiently muscular)

Specify whether BDD beliefs are currently characterized by:
Good or fair insight: Recognizes that BDD beliefs are definitely or probably not true, or that they may or may not be true
Poor insight: Thinks BDD beliefs are probably true
Absent insight (i.e., delusional beliefs about appearance): Completely convinced BDD beliefs are true

Rationale:
Criterion A: Changes clarify the criterion’s meaning and aim to make it more acceptable to patients. The changes are not intended to change caseness.

Criterion B: Examples are added to increase awareness of some of the common types of distress or impairment in functioning.
Criterion C: It is recommended that this criterion be limited to eating disorders, as to our knowledge, there are no other disorders that might easily be misdiagnosed as BDD. Before a final recommendation is made, it will be important to examine the DSM-V criteria for eating disorders, and examples of eating disorder NOS, to determine whether criterion C should or should not include eating disorder NOS.
The phrase “not better accounted for” appears to be confusing to some DSM users (for example, it is sometimes misconstrued to mean that BDD cannot be diagnosed if the patient also has an eating disorder, even if the patient also meets criteria for BDD). We recommend alternate wording, such as “is not restricted to,” which may be clearer.

Specifiers:

The muscle dysmorphia form of BDD appears to have several important differences from other forms of BDD (e.g., higher rates of suicidality and substance use disorders), and the treatment approach may require some modification. Thus, adding this specifier may have clinical utility.
There appear to be far more similarities than differences between delusional and nondelusional BDD, and thus it is recommended to combine BDD’s delusional and nondelusional variants into a single disorder and to eliminate the delusional variant from the psychosis section. The proposed specifier reflects the broad range of insight (including delusional thinking) that can characterize BDD beliefs. The proposed levels of insight are similar to categories in widely used scales for BDD, and they are the same as those proposed for OCD and olfactory reference syndrome.

Severity:

Yale-Brown Obsessive-Compulsive Scale Modified for BDD (BDD-YBOCS) (Phillips et al., 1997)
Insight dimensions (proposed for OCD, BDD, ORS, Hoarding Disorder): Brown Assessment of Beliefs Scale (BABS) (Eisen et al., 1998)