Body Dysmorphic Disorder
Original Editors - Sean Beard & Jimmy Crick from Bellarmine University's Pathophysiology of Complex Patient Problems project.
- 1 Definition/Description
- 2 Prevalence
- 3 Characteristics/Clinical Presentation 
- 4 Associated Co-morbidities
- 5 Medications
- 6 Diagnostic Tests/Lab Tests/Lab Values
- 7 Etiology/Causes
- 8 Systemic Involvement
- 9 Medical Management
- 10 Physical Therapy Management
- 11 Differential Diagnosis 
- 12 Resources
- 13 References
Body dysmorphic disorder (BDD) is a disorder characterized by extreme preoccupation with appearance that causes an individual personal distress in the presence of minimal or no physical defects. BDD is commonly considered to be an obsessive-compulsive spectrum disorder based on distinct similarities it shares with obsessive-compulsive disorder. Often, persons with BDD present first to dermatologists and/or plastic surgeons but necessitate referral to a psychiatrist or psychologist. Currently this disorder is classified as a somatoform disorder (a specific mental illness), but may also fall under the heading of an anxiety disorder. 
BDD is notable in that persons are concerned with a specific body part, rather than their entire body, which may help differentiate them from a person suffering from an eating disorder. 
First described as dysmorphophobia in 1886 in the European medical literature, it has since been described under several names which include: dermatologic hypochondriasis, beauty hypochondria, dermatologic nondisease, primary monosymptomatic hypochondriacal psychosis. 
BDD effects approximately 0.7% to 2.4% of general population. Specifically in the United States, 2.2% of men and 2.5% of women suffer from BDD. Typically patients notice symptoms during adolescence, on average at the age of sixteen years. In spite of early onset of disease, most afflicted persons defer seeking treatment until their early thirties. BDD seems to affect men and women equally, however some studies report a slightly higher frequency in women. Increased prevelance of BDD is seen in dermatological and cosmetic surgery practices.
Most common bodily areas of preoccupation include:
- Skin: scarring, color, wrinkles. Acne has been proposed as one of the most common complaints of BDD sufferers.
- Hair: going bald, excessive facial or body hair
- Facial features: nose, eyelids
- Breasts: size, shape
- Muscle: "muscle dysmorphia". Also has been described in the literature as the "Adonis Complex".
- Body height/weight
- Penis: "Koro" is a traditional Chinese misconception that the penis is shrinking
- Body odor
People that suffer from BDD frequently have a preoccupation with 5-7 distinct body parts. Men most commonly ascribe defects to their height, hair, body proportion, and genitals. Women are more likely to report concerns with their hips, thighs, buttocks, legs, breasts, and body weight. Obvious outward habits with people with BDD include compulsive behaviors such as:
- Constant seeking or avoidance of reflection in windows, mirrors, spoons
- Excessive grooming, or attempts to utilize dress to camouflage perceived defect(s)
- Overemphasis on diet and exercise
- Nervous tendency to pick at skin imperfections
- Comparing oneself to others
- Repeated measuring or touching of perceived defect
In extreme cases of BDD, people may resort to:
- Social isolation
- Substance abuse
- Seeking surgical intervention, either by self or professionally
Social manifestations of BDD may include:
- Over-reliance on positive feedback from spouse, parent, friends, etc.
- Decreased work and/or school performance and/or attendance.
- Maintenance interpersonal relationships becomes strained or impossible.
BDD is commonly associated with other co-morbid conditions, such as:
- Major depression: greater than 75% suffer from depression in their lifetime, making this the most common co-morbid condition.
- Anxiety: greater than 60% of people will experience anxiety along with BDD.
- Obsessive compulsive disorders: 30 to 78% of people with BDD will exhibit OCD tendencies with the most prevalent being hypochondriasis and trichotillomania
- Substance abuse: 25-30%, with alcohol being the most commonly abused drug.
- Social phobia: 38% of people with BDD will have this within the lifespan. Frequently this manifests before the onset of BDD. 
- Eating disorders: Anorexia and bulimia are relatively common.
- Personality disorders: including paranoia and personality-dependent disorders.
- Suicide: 58-80% of people with BDD experience suicidal thoughts, and 3-25% have attempted to end their life.
MedicationsSelective Serotonin Reuptake Inhibitors (SSRI) may help alleviate symptom severity and are the current medication of choice for treating BDD. Considering the proposed etiology by the neurobiological theory that Serotonin and Dopamine are abnormally metabolized, SSRI's help to maximize the effect of the body's own natural hormonal regulation. There is some evidence that SSRI's are more effective than non-SSRI's in terms of pharmacological treatment. Additionally, SSRI's are frequently used in treatment of many of the co-morbid conditions associated with BDD, including depression, social phobia, bulimia, hypochondriasis, and anxiety. In the United States, the most common brand names of SSRI's are Celexa, Lexapro, Prozac, Zoloft, Luvox, Paxil, and Anafranil. Though SSRI's have been well studied for the treatment of BDD, there are currently no FDA approved pharmacologic interventions for this disorder.
SSRI's are often used in conjunction with non-pharmacologic therapy (e.g., Cognitive-Behavioral Therapy). Caution must be taken when discontinuing an SSRI abruptly due to the incidence of relapse.
Other pharmacologic treatment options for BDD include anti-psychotics, benzodiazepines, lithium, serotonin-norepinephrine re-uptake inhibitors (SNRI), anti-epileptics, monoamine oxidase inhibitors (MAOI), and tricyclic antidepressants (TCA). These medications have only been studied in small trials, with TCA's and SNRI's demonstrating the greatest potential for therapeutic benefit.
Diagnostic Tests/Lab Tests/Lab Values
There are currently 3 diagnostic criteria for BDD:
- A preoccupation with an imagined or slight defect in appearance
- Marked distress causing impairments in social, occupational, or other areas of functioning resulting from the appearance preoccupation
- Physical preoccupation is not attributable to the presence of another psychiatric disorder
Diagnosis is made difficult because of the embarrassment that accompanies BDD, making a person with BDD reluctant to seek medical attention. More frequently plastic surgeons or dermatologists may suspect such a disorder based on frequent complaints and seeking surgical intervention. If a healthcare provider suspects BDD, then an immediate referral to a psychiatrist or psychologist is recommended.
- Neurobiological: There is some evidence to suggest a genetic component related to BDD. Studies estimate that approximately 20% of BDD sufferers have a first-degree relative with the disorder. Other hypotheses have theorized abnormal metabolism of serotonin and dopamine, inflammatory processes interfering with serotonin production, brain asymmetries specifically in the caudate nucleus, or injury to the frontotemporal region.
- Psychological: "Psychoanalytic explanations suggest that body dysmorphic disorder arises from an unconscious displacement of sexual or emotional conflict, or feelings of inferiority, guilt, or poor self image onto a body part." A Cognitive-Behavioral therapeutic approach suggests that emotional, cognitive, and behavioral factors combine to produce this disorder. Cognitive factors include an unrealistically perfect body image, excessive attention to perceived defect, or a misinterpretation of others responses to their perceived defect in social situations. Behavioral factors are theorized to stem from positive or negative reinforcement of certain physical characteristics and are likely related to social learning.
- Sociocultural: Physical and psychological changes occur due to reinforcement during adolescence (e.g., neglect, rejection, criticism) and may contribute to image dissatisfaction. Traumatic life events such as physical or sexual abuse may predispose a person to developing BDD. Even seemingly benign forms of teasing, if chronic in nature, have been proposed as contributing factors to development of this disorder - up to 60% of people with BDD report this in their social history.
Systemic manifestations of the disease are associated primarily with the comorbid conditions, as listed above. In particular, depression has been correlated with many systemic disorders and accompanying symptoms, including:
- Cardiovascular: chest pain, palpatations, tachycardia
- Gastrointestional: irritable bowel syndrome, GERD, ulcers
- Neurological: parasthesias, dizziness, memory lapses
- Musculoskeletal: weakness, fatigue, chronic low back pain, fibromyalgia
- Immune: autoimmunity, recurrent infections, environmental hypersensitivities
- Other: insomnia, headaches
Additionally, substance abuse may disrupt many organ systems, including:
Eating disorders are known to have deleterious effects on entire body systems, and are unique to each specific case and disorder.
Medical Management. In addition to pharmacological treatment, psychological intervention indicated. Currently Cognitive-Behavioral Therapy (CBT) is considered the gold standard treatment of BDD. CBT treatments may include elimination of excessive body checking, cognitive techniques to modify thoughts, intentional exposure to avoided situations, and coping mechanisms for their preoccupation. Ultimately the goal of CBT is to help the person to change the innacurate perception of their physical self and to place less emphasis on their physical appearance. Metacognitive therapy, which seeks to modify how a person thinks, has recently been used with limited success in the treatment of BDD.
In 2005, the United Kingdom created the National Institute for Health and Clinical Excellence (NICE) guidelines for treatment of BDD and OCD. These guidelines suggest a step-wise approach to treatment of these disorders. 
- Mild disorders: recommendation of a guided self-help book
- Moderate disorders: treatment utilizing SSRI's or CBT
- Severe disorders: combination of SSRI's and CBT
Physical Therapy Management
Persons with BDD are primarily treated by physicans and treatment of BDD specifically falls outside the scope of physical therapy practice. It is, however, crucial for physical therapists to be aware of BDD in patients as it relates to patient education, interpersonal interaction, personal wellness, and quality of life. Physical therapists are often the healthcare practitioner with whom patients feel most comfortable confiding in due to the nature of the profession and the personal time spent with the patients. Recognition of potential warning signs of BDD and appropriate referral is essential for physical therapy practice, particularly in direct access settings. The Brown Assessment of Beliefs Scale (BABS) is a reliable and valid psychometric outcome measure that physical therapists may utilize to quickly determine the degree of delusionality present in a patient suspected of having BDD.
Physical activity has been proven to provide positive psychological benefits in addition to physical wellness and thus may be an appropriate adjunct therapy for persons undergoing traditional BDD therapy. It has been shown that persons with body image disorders had improved subjective perception of their body image both immediately after exercise and longitudinally after completing an exercise regimen.
- Major depressive disorder
- Obsessive compulsive disorder
- Social phobia
- Eating disorders: Anorexia and bulimia
- Personality disorder
- Conversion Disorders
- Delusional Disorder
- Bipolar disorder
- Seasonal affective disorder
- Crerand CE, Franklin ME, Sarwer DB. Body dysmorphic disorder and cosmetic surgery. Plast Reconstr Surg. 2006;118(7):167e-80e.
- Bjornsson AS, Didie ER, Phillips KA. Body dysmorphic disorder. Dialogues Clin Neurosci. 2010;12(2):221-32.
- Gupta R, Huynh M, Ginsburg IH. Body dysmorphic disorder. Semin Cutan Med Surg. 2013;32(2):78-82.
- WebMD: Mental Health Center. Body Dysmorphic Disorder. http://www.webmd.com/mental-health/mental-health-body-dysmorphic-disorder (accessed 3 March 2014).
- Onlymyhealth. Understanding Body Dysmorphic Disorder. http://www.google.com/imgres?imgurl=&imgrefurl=http%3A%2F%2Fwww.onlymyhealth.com%2Funderstanding-body-dysmorphic-disorder-1285581494&h=0&w=0&sz=1&tbnid=LZ67Cr1MthucwM&tbnh=240&tbnw=160&zoom=1&docid=3ZhrRNCJI4ZE0M&ei=rJwUU-HHO-GfyQG-8IDQDw&ved=0CAUQsCUoAQ (Accessed 3 March 2014).
- Koran LM, Abujaoude E, Large MD, Serpe RT. The prevalence of bodyfckLRdysmorphic disorder in the United States adult population. CNS Spectr.fckLR2008;13(4):316-322.
- Healthy vs Living. Body Image. https://mrkhealth.pbworks.com/w/page/64690414/Body%20Image%20-%20Aaron,%20Siddharth,%20Kyler,%20Ben (accessed 3 March 2014).
- Ross J, Gowers S. Body dysmorphic disorder. Advances in Psychiatric Treatment. 17(2):142-149.
- Bowe WP, Leyden JJ, Crerand CE, Sarwer DB, Margolis DJ. Body dysmorphic disorder symptoms among patients with acne vulgaris. Journal of the American Academy of Dermatology. 2007 Aug 1;57(2):222-30.
- Danilova D, Diekhoff GM, Vandehey MA. A Multidimensional Scaling Analysis of Male Body Perception in Men With Muscle Dysmorphia: "The Adonis Complex". International Journal of Men's Health. 2013;12(2):83-105.
- Phillips, K. A., Menard, W., Fay, C., et al. DemographicfckLRcharacteristics, phenomenology, comorbidity, and familyfckLRhistory in 200 individuals with body dysmorphic disorder.fckLRPsychosomatics 46: 317, 2005.
- Gunstad, J., and Phillips, K. A. Axis I comorbidity in bodyfckLRdysmorphic disorder. Compr. Psychiatry 44: 270, 2003.
- Phillips KA. Suicidality in Body Dysmorphic Disorder. Prim psychiatry. 2007;14(12):58-66.
- Phillips KA, Hollander E. Treating body dysmorphic disorder with medication: evidence, misconceptions, and a suggested approach. Body Image. 2008;5(1):13-27.
- Neurotic Physiology Blog. http://scientopia.org/blogs/scicurious/2009/01/02/lets-talk-about-your-prozac-addiction/ (accessed 6 March 2014).
- American Psychiatric Association. Diagnostic and StatisticalfckLRManual of Mental Disorders, Fourth Edition, Text Revision.fckLRWashington, D.C.: American Psychiatric Association, 2000.
- Phillips, K. A. Body dysmorphic disorder: The distress of imagined ugliness. Am. J. Psychiatry 148: 1138, 1991.
- Goodman CC, Snyder TE. Differential Diagnosis for Physical Therapists, Screening for Referral. Saunders; 2012.
- Rabiei M, Mulkens S, Kalantari M, et al. Metacognitive therapy for body dysmorphic disorder patients in Iran: acceptability and proof of concept. J Behav Ther Exp Psychiatry. 2012;43:724-729.
- National Collaborating Centre for Mental Health (UK). Obsessive-Compulsive Disorder: Core Interventions in the Treatment of Obsessive-Compulsive Disorder and Body Dysmorphic Disorder. Leicester (UK): British Psychological Society; 2006. (NICE Clinical Guidelines, No. 31.) Available from: http://www.ncbi.nlm.nih.gov/books/NBK56458/
- Carnazzo Psychological Services. http://www.drcarnazzo.com/cognitive-therapy.html (accessed 6 March 2014).
- Phillips KA, Hart AS, Menard W, Eisen JL. Psychometric evaluation of the Brown Assessment of Beliefs Scale in body dysmorphic disorder. J Nerv Ment Dis. 2013;201(7):640-3.
- Scully D, Kremer J, Meade MM, Graham R, Dudgeon K. Physical exercise and psychological well being: a critical review. British Journal of Sports Medicine. 1998;32(2):111-120.
- Campbell A, Hausenblas HA. Effects of exercise interventions on body image: a meta-analysis. J Health Psychol. 2009;14(6):780-93.
- Ahmed I. Body Dysmorphic Disorder. Medscape. January 17, 2014. Available at: http://emedicine.medscape.com/article/291182-differential (accessed 6 March 2014).