BODY DYSMORPHIC DISORDER

BODY DYSMORPHIC DISORDER - Jennifer L.Schott, MD
BASICS
DESCRIPTION
According to the DSM-IV-TR, body dysmorphic disorder is a preoccupation with an imagined defect in appearance that causes clinically significant distress or impairment in social, occupational, or other important areas of function that is not accounted for by another mental disorder. If there is a minor physical anomaly, the concern is excessive. (1)
EPIDEMIOLOGY
• May be equally common in men and women
• Different cultural beliefs may influence or amplify preoccupations.
• Usually begins during adolescence with an average age of onset of 17 years (1)
- Adolescents usually present similar to adults
- Can present in childhood, often with refusing to attend school or planning suicide (2)
• Onset can be gradual or abrupt
• Often a delay in diagnosis until 10-15 years after the onset (1)
Prevalence
• 0.7% in the general community
• 5-40% in individuals with Anxiety or Depressive Disorders (3)
• 6-15% in cosmetic surgery patients and in dermatologic clinics (1)
RISK FACTORS
• Genetic predisposition
• Shyness, perfectionism, or anxious temperament
• Childhood adversity
- Teasing or bullying
- Poor peer relationships
- Social isolation
- Lack of support of family
- Sexual abuse
• History of dermatological or other physical stigmata
• Being more aesthetically sensitive than average
• Low self esteem (3)
PATHOPHYSIOLOGY
• Not known
• A cognitive behavioral model has been described in which an external representation of the person's appearance creates a distorted mental image that through selective attention increases the awareness of the image and its specific features. The preoccupation of the distorted image is maintained by different safety and submissive behaviors to decrease the scrutiny by others but actually tends to increase the individual's doubts and reinforces the behavior.
• Possible lesions in the frontostriatal connections, which cause abnormal verbal and nonverbal encoding strategies leading to executive memory deficits (3)
ETIOLOGY
Not known but likely multifactorial involving genetic, biological, and environmental factors
ASSOCIATED CONDITIONS
• Depression
• Social phobia
• Bipolar disorder
• Eating disorders
• Obsessive-compulsive disorder
• Suicide
• Delusional disorder, somatic type (1)

DIAGNOSIS
SIGNS AND SYMPTOMS
• Preoccupation that 1 or more of their features are unattractive, ugly, or deformed
• Can involve any part of the body but usually involves the skin, hair, or facial features (1)
- Women are more likely to be preoccupied with their weight, hips, legs, and breasts
- Men are more likely to be preoccupied with their height, body hair, body build, and genitals (4,5)
• Nature of the preoccupation can change with time
• Have little insight
• Tend to display delusions of reference
• Large amounts of time are consumed by behaviors to examine the perceived defect repeatedly, disguise it, or improve it
- Mirror gazing
- Excessive grooming
- Camouflaging the "defect"
- Skin picking
- Reassurance seeking
- Dieting
- Pursuing dermatological treatment or cosmetic surgery
• Tend to avoid social interactions
• Trouble staying in school, maintaining a job, or maintaining significant relationships
- Tend to be unhappy with results of dermatologic and cosmetic procedures (1)
History
• Determine and validate the patient's concern
• Determine the severity of the disorder
• Quantify the amount of time spent worrying about the "distorted" appearance
• Determine what is done to hide or eliminate the problem
• Determine the degree to which the defect affects their school, job, or social life
• Rule out other psychiatric disorders (6)
Physical Exam
• Important to do a mental status examination
- Look for
 Depression
 Suicidal ideation
 Anxiety
- Rule out organic factors by reviewing
 Orientation
 Memory
 Ability to concentrate
• Rule out actual physical pathology
DIFFERENTIAL DIAGNOSIS
• Normal concerns about appearance
• Eating disorders
• Gender identity disorder
• Major depressive episode
• Narcissistic personality disorder
• Avoidant personality disorder
• Social phobia
• Schizophrenia
• Obsessive-compulsive disorder
• Trichotillomania
• Hypochondriasis
• Delusional disorder, somatic type
• Koro: A culture-related syndrome seen in Southeast Asia
- Involves a preoccupation that the genitals (penis, labia, nipples, or breast) is shrinking and is disappearing into the abdomen (1)
TREATMENT
SPECIAL THERAPY
• Refer to a psychiatrist for diagnosis and therapy
• Cognitive behavior therapy has been shown to be very effective (7)[B]
- Behavioral experiments
- Graded exposure tasks
- Imagery rescripting
- Cognitive restructuring
- Reverse role playing
- Relaxation
• Support groups (7)[C]
• Psychotherapy may be effective (7)[C]
• Therapy with and for family members, spouses, or significant others
MEDICATION (DRUGS)
First Line
Selective Serotonin-reuptake inhibitors (SSRI) (7)[B]
• Not an approved use by the FDA
• Patients with and without a delusional disorder did equally well with an SSRI
• Maximum tolerated dose should be taken for at least 12-16 weeks
• Dosages may need to be higher than typically recommended for an eating disorder (3,6,7)
Second Line
Adding a low dose antipsychotic drug to an SSRI if there is failure to respond to 2 or more SSRIs (2)[C]
SURGERY
Cosmetic surgery and dermatologic procedures may have potential benefits or no benefit
• Difficult patients for dermatologists and plastic surgeons due to tendency to insist on repeated procedures, are often unhappy with the results, and require repeated reassurance (3)
FOLLOW-UP
PROGNOSIS
Continuous course with periods of waxing and waning in the intensity of symptoms
• The longer the duration and the more severe the symptoms, the less the chance of partial or full remission (8)
COMPLICATIONS
• Repeated surgical or dermatological procedures
• Suicide
• Comorbid conditions
• Poor social relations
• Poor self esteem
• Inability or limited ability to function in society
PATIENT MONITORING
• Close monitoring by psychiatrist
• Regular counseling
REFERENCES
1. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Addition, Text Revision. Washington, DC: American Psychiatric Association, 2000;507-510.
2. Albertini RS, Philips KA. Thirty-Three cases of body dysmorphic disorder in children and adolescents. J Am Acad Child Psy. 1999;38:453-459.
3. Veale D. Body dysmorphic disorder. Postgrad Med J. 2004;80:67-71.
4. Perugi G, Akiskal H, Giannotti D, Frare F, Di Vaio S, Cassano G. Gender-related differences in body dysmorphic disorder. J Ner Ment Dis. 1997;185:578-582.
5. Philips KA, Diaz SF. Gender differences in body dysmorphic disorder. J Ner Ment Dis. 1997;185:570-577.
6. Slaughter JR, Sun SM. In pursuit of perfection: A primary care physician's guide to body dysmorphic disorder. Am Fam Physician. 1999;60:1738-1742.
7. Ipser JC, Stein DJ. Pharmacotherapy and psychotherapy for body dysmorphic disorder. The Cochrane Library. 2005;4.
8. Philips KA, Pagano ME, Menard W, Fay C, Stout RL. Predictors of remission from body dysmorphic disorder: A prospective study. J Ner Ment Dis. 2005;193:564-567.