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Imagine being disgusted every time you glance at a mirror but at the same time, you cannot look away. How you look preoccupies your mind, and every thought is negative. No makeup is good enough, no clothes are pretty enough to distract from what you so firmly believe are inexcusable flaws in your appearance. This is the daily plight of people with Body Dysmorphic Disorder.
These people suffer persistent, disturbing obsessions about their physical appearance. Depending on the severity of the disorder, patients may think they are unattractive, ugly, and even grotesque. The three most common subjects of patients’ attention are the skin (73% of patients), the hair (56%), and the nose (37%). Most patients report multiple areas of concern, with the average being 5-7 different ones.
It takes over
These preoccupations consume 3-8 hours a day on average. The most severely affected quarter of patients spent over 8 hours a day on them. They engage in multiple compulsive behaviors that are unwanted and increase anxiety. Patients spend this time examining their reflections and adjusting their appearance via excessive personal grooming.
They frequently seek emotional support from others. They attempt to hide their perceived defects by applying extra makeup, tanning excessively, or wearing clothes and hats to hide themselves. Patients frequently touch worrisome areas and often pick their skin, hair, and nails, frequently causing additional damage and scarring.
About 48% of these patients end up receiving cosmetic surgery or dermatologic treatments, but very few patients (2.3%) have any long term emotional benefit from these procedures. Even though patients with muscle dysmorphia usually have normal sized or large muscles, they spend inordinate amounts of time regulating their diet and working out. Additionally, 21% of men with muscle dysmorphia use anabolic steroids to boost gains from exercise. These patients have higher social anxiety in general, and severe symptoms lead patients to avoid social situations.
Risk Factors and Causes
Diagnosis generally comes at an early age, with 70% of patients being diagnosed before age 18. The average age at diagnosis is 16, and the most common age at diagnosis is 13. Onset is usually gradual, and the disorder is chronic. The treatment goals are to reduce severity and improve functioning.
About 2.4% of the U.S. population is afflicted with Body Dysmorphic Disorder, with slightly more women affected than men. These people frequently suffered abuse during childhood: 28-56% report emotional abuse, 14-34.7% physical abuse, and 22-28% sexual abuse. These adverse conditions frequently continue in adolescence, where patients report significantly more teasing by peers regarding physical appearance. Body Dysmorphic Disorder usually begins in adolescence, and teasing about appearance contributes the development and reinforcement of the negative self image associated with the disorder.
In the family
Body Dysmorphic Disorder has a significant genetic component. First-degree family members of these patients have 3-4 times the average risk for developing the disorder as well. There is genetic cross-over with Obsessive-Compulsive Disorder, which is six times more common than average in first degree relatives of patients with Body Dysmorphic Disorder.
Patients with Body Dysmorphic Disorder have a negative cognitive bias in their assessments of social and body-related situations. They also have a bias for others’ neutral facial expressions, which they tend to view as negative. Furthermore, they are more focused on details in visual processing, so much so that they neglect the greater picture. These patients process faces differently from others, focusing on details rather than the whole picture and thus are more likely to pick out small negative aspects.
Major Depressive Disorder is the most commonly associated psychiatric disorder, occurring in 36-76% of different samples of Body Dysmorphic Disorder patients. Social Anxiety Disorder strikes 37-39% of these patients, and Obsessive Compulsive Disorder appears in 32-33%. Substance use disorders hit 36-48% of these patients. Eating disorders like Bulimia Nervosa and Anorexia Nervosa happen in 8-16% of patients with Body Dysmorphic Disorder.
Diagnosing Body Dysmorphic Disorder
People with Body Dysmorphic Disorder agonize daily over supposed imperfections in their physical appearance that, for the most part, only they notice. They feel compelled to engage in repetitive acts associated with their focus on their image, such as looking in the mirror, seeking emotional support from others, and personal grooming. They also spend significant amounts of time comparing themselves to others.
Unlike in Obsessive Compulsive Disorder, where the compulsions reduce anxiety, the compulsive acts of Body Dysmorphic Disorder often increase anxiety and make the patients feel even worse. The disorder significantly disrupts social, work, and home life. Symptoms related to body appearance concerns that result from an eating disorder do not qualify people for body dysmorphia.
The patient’s concerns are sometimes specifically related to musculature, with patients believing that certain parts of their body are inadequately muscular. This symptom is known as muscle dysmorphia and occurs almost exclusively in men, with 22.2% of men with Body Dysmorphic Disorder experiencing muscle dysmorphia.
People can have a wide range of insight. Some understand their thoughts about their bodies are unrealistic while others fully believe in their perceived imperfections. On average, insight is generally low, with different studies reporting that 27-60% of Body Dysmorphic Disorder patients are completely convinced their beliefs about their bodies are true. Two-thirds people have delusions of reference, believing that others are looking at them, talking about them, and treating them negatively because of their perceived imperfections. Patients with delusions generally have more severe forms of the disorder and worse level of functioning. Adolescent patients are more likely to have delusions than adult patients.
Treating Body Dysmorphic Disorder
Selective serotonin reuptake inhibitors (SSRIs) are the primary medication treatment for Body Dysmorphic Disorder and have the most supporting evidence. Response rates (defined as a 30% or greater reduction in overall symptom severity) for SSRIs are quite good. They range from 53% for Prozac (fluoxetine), 63% for Luvox (fluvoxmine), 65% for Anafranil (clomipramine), and 73% for Celexa (citalopram) and Lexapro (escitalopram). These drugs are convenient because they also treat the frequently comorbid Major Depressive Disorder and Obsessive-Compulsive Disorder. In severe cases, they can also be used as a precursor to therapy to decrease delusions and increase engagement in therapy.
Cognitive Behavioral Therapy
CBT is the first-choice psychotherapy for Body Dysmorphic Disorder. Specialized CBT that targets Body Dysmorphic Disorder challenges patients’ beliefs that they are disfigured. It emphasizes the idea that they have a distorted view of their own body. Therapy starts as a 3-4 month trial period during which they will live as if they have a normal appearance. This means they stop the associated compulsive grooming, checking, camouflaging, and avoidance behaviors.
One of several skills people learn is “imagery re-scripting,” where patients go over past traumatic experiences that negatively affected their self-image first from the viewpoint of a child then from that of an adult. The goal is to get patients to stop reacting to these past experiences as though they were in the present.
Patients also learn to refocus their attention externally in anxiety-provoking situations, rather than focusing on themselves and their appearance. Therapy also challenges patients’ checking behaviors, especially regarding mirrors. They are encouraged to only use mirrors to perform hygienic tasks, such as shaving and brushing teeth. They need to only use large mirrors at a distance sufficient to give a full picture of the face or body and not to use them at the behest of an urge or when they feel ‘ugly.’
Managing Body Dysmorphic Disorder
High suicide risk
People with Body Dysmorphic Disorder are at high risk of suicidal behaviors. Roughly 78-81% contemplate suicide at some point, and 24-28% attempt it. Patients with muscle dysmorphia and adolescents are at especially high risk, with 50% and 44.4%, respectively, attempting suicide.
Early recognition and treatment are key to preventing negative impacts on adolescent patients’ academics. About 18-22% of patients end up dropping out of school because of the disorder. One third of patients have at least some trouble attending school consistently. Just as many have been homebound for at least a week at some point, and 2 in 5 have been in a psychiatric hospital for the disorder.
Difficulty accepting treatment
Delusional beliefs often impede diagnosis and treatment because patients often refuse to see a physician. This is usually because either they do not want them to see their perceived physical flaws, or they want cosmetic procedures to change their appearance. Given that only a fraction (41% in one study) of these patients proactively discuss their symptoms with their physicians, parents or partners may need to provide symptom information to clinicians for patients. Therapy sessions over the phone or via the computer can also help patients initiate the process.
Receiving cosmetic procedures rarely helps and often harms patients with BDD. Two separate studies found that only 7.3% and 3.6% of BDD patients who underwent a cosmetic procedure had a decrease in their symptoms afterward. Patients who feel satisfied are likely to preoccupy over how long the improvement will last. Alternatively, they end up changing their focus to a different body part.