Body dysmorphic disorder
Synonyms and keywords: BDD

# Overview
Body dysmorphic disorder (BDD) is a mental disorder that involves a disturbed body image where there is an excessive preoccupation with the physical appearance despite the fact there may be no noticeable disfigurement or defect. Common areas of concern in most people suffering from BDD include perceived flaws relating to the face, nose, eyes, skin, and hair. BDD combines obsessive and compulsive aspects, which links it to the OCD spectrum disorders. People with BDD may engage in compulsive mirror checking behaviors or mirror avoidance, typically think about their appearance for more than one hour a day, and in severe cases may drop all social contact and responsibilities as they become homebound. The disorder is linked to an unusually high suicide rate among all mental disorders.

# Historical Perspective
BDD was first documented in 1886 by the researcher Morselli, who called the condition simply "Dysmorphophobia". BDD was first recorded/formally recognized in 1997 as a disorder in the DSM; however, in 1987 it was first truly recognized by the American Psychiatric Association.
In his practice, Freud eventually had a patient who would today be diagnosed with the disorder; Russian aristocrat Sergei Pankejeff, nicknamed "The Wolf Man" by Freud himself in order to protect Pankejeff's identity, had a preoccupation with his nose to an extent that greatly limited his functioning.

# Causes
The exact etiology of BDD is unclear, but it is likely an interplay in social, psychological, and biological factors. 

## Social Factors
Individuals with BDD have suffered from some form of abuse in the past. These experiences comprised emotional neglect in 68%, emotional abuse in 56 %, physical abuse in 34.7%, and sexual abuse in 28% of patients.  

## Neurobiological Model for BDD

### Detailed processing and visual processing streams
A dysfunction in visual processing systems accounts for the heightened detail processing in BDD patients. This is due to the observed early travel of first-order visual information from V1 and V2 areas to temporal regions in the left hemisphere, where detail and structure are encoded. In addition, there is the faulty formation of holistic elements of visual information due to decreased use of the processing of second-order visual information, as evidenced by decreased activity in the lateral occipital cortex and precuneus. These findings explain the enhanced awareness of perceived imperfections in BDD patients.    

### Frontostriatal systems
Increased activity and reduced grey matter volumes in the frontostriatal and subcortical regions are linked to BDD patients' repetitive and compulsive behaviors, which is similarly observed in OCD patients.This is supported by abnormal circuitry seen in the inferior occipitofrontal fasciculus, a pathway that connects the frontal and occipital lobes via the caudate. The caudate nucleus seems to play an essential role in inappropriately mediating motor inhibition.  

### Temporolimbic systems
The limbic system is also involved in BDD. In particular, the right amygdala demonstrates hyperactivity during visual tasks and mediates the relationship between anxiety and ventral visual system activation. This results in heightened emotions to visual information. 

## Genetic Factors
A genetic component may also be involved in BBD. Patients with BDD have a family member with a similar condition in 8% of patients, while 7% of BDD patients have first-degree family members with OCD. 

# Differential Diagnosis
Body dysmorphic disorder must be differentiated from: 
- Anxiety disorder
- Eating disorders
- Illness anxiety disorder
- Major depressive disorder
- Other obsessive-compulsive disorders
- Psychotic disorders

# Epidemiology and Demographics

## Prevalence
The prevalence of BDD is at 0.7-2.4% in the general population making it more common than other psychiatric disorders such as anorexia nervosa or schizophrenia. In clinical settings, BDD seems to have a prevalence of 9-13% in dermatology settings, 3-53% in cosmetic surgery settings and it coexists with OCD in 8-37% of patients. 
Considering how common this condition is, many individuals dont report their symptoms due to embarrassment. 

## Gender
BDD affects more women than men (2.5% vs 2.2%) and the average onset is at 17 years old.

# Risk Factors
Some of risk factors include: 
- First-degree relatives of patients with obsessive compulsive disorder (OCD)
- History of childhood abuse

# Natural History, Complications, and Prognosis

## Natural History
BDD usually develops in adolescence, a time when people are generally most sensitive about their appearance. However, many patients suffer for years before seeking help. When they do seek help through mental health professionals, patients often complain of other symptoms such as depression, social anxiety or obsessive-compulsive disorder, but do not reveal their real concern over body image. Most patients cannot be convinced that they have a distorted view of their body image, due to the very limited knowledge of the disorder as compared to OCD or others.  
Male patients have more risk of developing the obsession around the genitalia and females have higher risk of developing eating disorders associated with the BDD.

## Complications

### Suicide Risk
- The suicide rates in patients with BDD are high at all ages, with a higher incidence in adolescent patients.
- Risk factors associated with completed suicide in patients with BDD are suicide thoughts and previous attempts, association with major depressive syndrome and demographic locations associated with high rates of suicide.
- Phillips & Menard (2006) found the completed suicide rate in patients with BDD to be 45 times higher than in the general US population. This rate is more than double that of those with Clinical depression and three times as high as those with bipolar disorder. There has also been a suggested link between undiagnosed BDD and a higher than average suicide rate among people who have undergone cosmetic surgery.

### Functional Consequences of BDD
- Impaired psychosocial development which can range from mild (the patient avoids social situations) to severe (the patient doesn't leave the house).
- The severity of the disorder is usually directly associated with the degree of psychosocial impairment.
- Chronically low self-esteem is characteristic of those with BDD due to the value of oneself being so closely linked with their perceived appearance. BDD causes chronic social anxiety for those suffering from the disorder

## Prognosis
Many individuals with BDD have repeatedly sought treatment from dermatologists or cosmetic surgeons with little satisfaction before finally accepting psychiatric or psychological help. Treatment can improve the outcome of the illness for most people. Other patients may function reasonably well for a time and then relapse, while others may remain chronically ill. Research on outcomes without therapy is not known but it is thought the symptoms persist unless treated. 

# Diagnosis

## Diagnostic Criteria

### DSM-V Diagnostic Criteria for Body Dysmorphic Disorder Body Dysmorphic Disorder
- One must also specify if a patient with BDD has muscle dysmorphia where one seems to be preoccupied in a too small or insufficiently muscular physique even though they have a normal-looking build.
- In addition, the degree of insight must also be evaluated .

## Symptoms
Symptoms of body dysmorphic disorder include:
- Compulsive mirror checking, glancing in reflective doors, windows, and other reflective surfaces
- Alternatively, an inability to look at one's own reflection or photographs of oneself; often the removal of mirrors from the home
- Compulsive skin-touching, especially to measure or feel the perceived defect
- Reassurance-seeking from loved ones
- Social withdrawal and co-morbid depression.
- Obsessive viewing of favorite celebrities or models the person suffering from BDD may wish to resemble
- Excessive grooming behaviors: combing hair, plucking eyebrows, shaving, etc
- Obsession with plastic surgery or multiple plastic surgeries with few satisfactory results for the patient
- In obscure cases patients have performed plastic surgery on themselves, including liposuction and various implants with disastrous results

## Common Locations of imagined Defects
In research carried out by Dr. Katharine Philips, involving over 500 patients, the percentage of patients concerned with the most common locations were as follows:
- Skin (73%)
- Hair (56%)
- Nose (37%)
- Weight (22%)
- Stomach (22%)
- Breasts/ Chest/ Nipples (21%)
- Eyes (20%)
- Thighs (20%)
- Teeth (20%)
- Legs (Overall) (18%)
- Body Build/ Bone Structure (16%)
- Ugly Face (General) (14%)
- Lips (12%)
- Buttocks (12%)
- Chin (11%)
- Fingers
- Eyebrows (11%)
People with BDD often have more than one area of concern.
Source:  The Broken Mirror, Katharine A Philips, Oxford University Press, 2005 ed, p56

# Treatment
- The combination of Cognitive Behavioral Therapy (CBT) and Selective Serotonin Reuptake Inhibitors (SSRIs) are the mainstay treatments for BDD.
- CBT involves psychotherapy centered on developing coping mechanisms by altering repetitive behavior patterns and thoughts. Strategies involve gradual sensitization of fear-inducing circumstances and retraining of thoughts. They are administered for 12-22 weeks of weekly sessions. 
- SSRIs, more commonly fluoxetine and escitalopram, are used to treat BDD and its accompanying comorbidities such as major depressive disorder, (social anxiety disorder, and OCD. The incorporation of clomipramine is also initiated in some cases where SSRIs may not be of benefit. What should be noted with the use of SSRIs in the treatment of BDD is that they require higher doses compared to doses used to treat other psychiatric conditions. Typically, observed response to SSRI requires 12-16 weeks to determine response.