Print version ISSN 0365-0596
An. Bras. Dermatol. vol.84 no.6 Rio de Janeiro Nov./Dec. 2009
CONTINUING MEDICAL EDUCATION
Body dysmorphic disorder in dermatology: diagnosis, epidemiology and clinical aspects*
Luciana Archetti ConradoI
IMaster in Health Sciences
University of Sao Paulo School of Medicine (FMUSP) - Sao Paulo (SP), Brazil
Cosmetic concerns are becoming increasingly common in view of the obsession with the perfect body and skin. Dermatologists are often seen to evaluate and treat these conditions. Therefore, it is important to acknowledge the existence of Body Dysmorphic Disorder, also known as dysmorphophobia. Despite being relatively common, this disorder has not been well researched. Sometimes causing impairment, the disease involves a distorted body image perception characterized by excessive preoccupation with a perceived defect. Most of the patients experience some degree of impairment in social or occupational functioning and, as a result of their obsessive concerns, they may develop compulsive behaviors. In severe cases, there is a risk of suicide. Most individuals do not acknowledge that their defect is minimal or nonexistent and seek out cosmetic treatments for a psychiatric disorder. The prevalence of this disorder among the general population ranges from 1 to 2 % and in dermatological and cosmetic surgery patients, from 2.9 to 16%. The training of professionals to systematically investigate, diagnose, and refer these patients to adequate psychiatric treatment is essential, considering the high prevalence of Body Dysmorphic Disorder in dermatological patients and the fact that cosmetic treatments rarely improve their condition.
Keywords: surgery, plastic; dermatology; body image; prevalence; obsessive-compulsive disorder; somatoform disorders; somatoform disorders; somatoform disorders/epidemiology
Body image dissatisfaction seems to be common1 among the general population. However, the level of preoccupation caused by the low self image may vary among individuals, reaching a degree at which these preoccupations may interfere with the daily functioning. Body image dissatisfaction plays an important role in a large number of psychiatric disorders including eating disorders, social phobia, gender identity disorder, but mainly in the psychiatric condition that is more relevant to dermatologists - the Body Dysmorphic Disorder (BDD). Extreme body image dissatisfaction is the core symptom of BDD, this being the only diagnostic category in the American "Diagnostic and Statistical Manual of Mental Disorders" (DSM) that is directly related to complaints about body image.1
Body Dysmorphic Disorder (BDD) is relatively common, sometimes impairing, and involves a distorted perception of body image characterized by an excessive preoccupation with an imagined or minimal body defect 2.
Despite the important social aspect involving this disorder, it had been little study until recently, and failed to be recognized or diagnosed by health professionals3.
HISTORY OF THE DIAGNOSIS OF BDD
BDD was first described in 1886 by Enrico Morselli, and initially named "dysmorphophobia"42.
Janet (1903) described "l'obsession de honte du corps" (obsession with shame of the body), Kraeplin (1909) called it "dysmorphophobic syndrome", and the Japanese named it "shubo-kyofu".5
The first case reports of patients with symptoms consistent with BDD in the cosmetic surgery and dermatology literature were published before this disorder was included in the "Diagnostic and Statistical Manual of Mental Disorders" (DSM) of the American Association of Psychiatry, or in the World Health Organization's "International Classification of Mental and Behavioural Disorders" (ICD). Reports of the 1960's describe surgical patients with minimal deformities and "insatiable"6 in relation to the performance of cosmetic plastic surgeries. In dermatology literature we found descriptions of patients whose clinical presentation is called dysmorphophobia and "dermatological nondisease"7, dysmorphic syndrome, or also dermatological hypochondria8. The term "psychogenic excoriations" was mainly used in the dermatology literature for patients who frequently manipulated their skin9. In those reports, the patients showed high levels of dissatisfaction with the outcomes of objectively acceptable treatments, or further focused their preoccupation on another part of their body9. Since the diagnostic criteria of these studies were not strict, perhaps some patients, but not all of them, had BDD.
Despite having been described more than one century ago, BDD was not included in the diagnostic systems until 1980, and its classification is discussed until today10. For a long time, BDD was considered a symptom of psychiatric diseases such as schizophrenia, mood disorders, or personality disorders11. In the American psychiatric nosography, BDD is first mentioned in the "Diagnostic and Statistical Manual of Mental Disorders (DSM)" - III (1980)12 as an Atypical Somatoform Disorder, and in DSM III-R (1987)13, with the non-delusional and delusional variants.
Somatoform Disorder is defined as "the presence of physical symptoms suggesting a general medical condition, that however cannot be fully explained by a general medical condition, the direct effect of a substance or another mental disorder"14.3
In the American DSM-IV (1994)14, this condition is classified as "Body Dysmorphic Disorder" (BDD), one of the manifestations of the Somatoform Disorders.1
More recently, BDD has been recognized as a specific syndrome possibly with an autonomous diagnostic category, or as a manifestation of the so-called spectrum of the Obsessive Compulsive Disorder (OCD), which includes disorders that feature psychopathologic characteristics, clinical outcome characteristics, comorbidity pattern, and responses to treatment similar to those of OCD15-17; or also as related to the spectrum of affective disorders18. However, the definitive conclusions on these relations are still limited by the scarce knowledge about the etiopathogenesis of OCD.
DIAGNOSTIC CRITERIA FOR BODY DYSMORPHIC DISORDER IN THE DSM-IV AND IDC-10
BDD is defined as a preoccupation with a "defect" in appearance. DSM-IV lists three diagnostic criteria for BDD:
A) Preoccupation with an imagined defect in physical appearance; if a slight anomaly 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 such as anorexia nervosa.
Application of the diagnostic criteria for BDD in the population of patients with cosmetic complaints may be challenging.
If applied in an independent fashion in the population that seeks cosmetic dermatology professionals, the first diagnostic criterion (A) will be positive in most of the patients. Many patients wish to correct minimal defects or improve normal aspects, and the professionals are trained to identify and correct these small imperfections in appearance. Additionally, in this population, some degree of dissatisfaction with the part of the body for which the treatment is desired is the rule19.
The second diagnostic criterion (B), that is, the degree of dissatisfaction and impairment in daily functioning, may be the best indicator of BDD in these patients8. For instance, individuals who report that their complaints in relation to appearance interfere with their ability to keep a job meet the criteria for BDD. In contrast, the diagnosis of BDD is less likely to be made in patients who deny that their preoccupations significantly interfere with their social and occupational functioning.
Criterion C should be applied to exclude mainly eating disorders. For instance: a patient with anorexia nervosa who has preoccupations with body image focused only in "being too fat" should only be diagnosed with anorexia nervosa and not with BDD. However, both disorders may occur simultaneously20.
In IDC-1021, the criterion for the diagnosis of BDD requires that the patients seek medical attention for their complaints about appearance. Phillips20 points out an important limitation of this criterion, considering that the patients with BDD may have not sought medical care for different reasons (ex.: for not having health insurance or access to treatment, or for the condition of social isolation in which they may be).
CLINICAL FEATURES OF BODY DYSMORPHIC DISORDER
No extensive or complete epidemiological studies on BDD are available in the literature. However, retrospective studies22 and data from the first prospective study show important descriptive aspects of the clinical features23.
The core issue of BDD is one's belief of being deformed, ugly, or not being attractive in relation to some aspect. Actually, the defect in appearance is minimal or inexistent. This cognitive distortion becomes obsession, and the thoughts cause distress, are hard to resist and control24, and may consume hours in a day25. As a matter of fact, the "defect" is frequently unnoticeable to an interlocutor at a normal conversation distance. However, they are perceived by the patient as a devastating defect causing anxiety and distress, and making them constantly and irrationally seek for perfection and symmetry in their appearance26. To differentiate BDD from normal appearance concerns, which are common in the general population, the preoccupation must cause significant distress or impairment of daily functioning25.
These preoccupations more commonly involve areas of the face (skin, hair and nose), although any part of the body could be the focus of concern. The patients frequently have complaints related to acne, wrinkles, and expression lines; changes in complexion (for instance, they believe that their skin is too ruddy or too pale) or in skin texture; scars and striae; "marks" such as nevocellular nevus, thinning hair or excess of body hair; and complaints related to the size and shape of the nose7. In addition to the face, men's major focus are concerns about their genitals, weight, hair and body build, whereas women more typically report preoccupations with their weight, hips, legs and breasts27. On average, people with BDD report concerns with five to seven parts of the body during the course of the disorder28.
The patients reported inability to stop their thoughts on their perception of the defect, and that it is hard to control their obsession, which can become more intense in situations in which the individual feels pressured by the expectation of being observed, as in social situations29. In an attempt to reduce the distress caused by their beliefs, the patients resort to strategies which usually are unsuccessful or minimally successful.
The most common behaviors are: constant reassurance about their appearance by checking it in the mirror or reflective surfaces (for example, glass) in order to be sure that they are normal or "acceptable"; camouflaging of the "defect" with the hair, make-up, sunglasses or clothing; control of body position to avoid that the "defect" is observed; excessive personal care ("grooming behaviors") in beauty salons, with changes in color and hair cut; or by using make-ups, cosmoceutic products and dermatological treatments in excess (sunblock, retinoic acid). The behaviors are variable and unlimited: "artificial tanning"30; frequent diets; excessive work-out and use of anabolic steroids characterizing "Muscular Dysmorphia"31; habit of touching or measuring body parts and comparing their appearance to that of famous people; buying beauty products or clothes in excess; reading about physical appearance and body32.
Some behaviors such as skin or hair manipulation seem to be important in BDD. Most people show these behaviors to a limited extent, at various times in their life33. These behaviors are complex and become pathological (pathological skin picking or trichotillomania) depending on their focus, duration and extent, on the resulting problems, as well as on the reasons and associated emotions. Pathological excoriations ("skin picking") and trichotillomania are recurrent and may result in considerable skin and hair damage.
Pathological excoriations ("skin picking")34 have been recognized in Dermatology for many years, and are called "dermatillomania" or "neurotic excoriations"7. The patients report that this behavior is compulsive and irresistible, and may frequently worsen a previous dermatosis (for example, mild acne)33. Pathological skin picking may be a symptom of several psychiatric disorders and was reported in 27% of the participants in a study of patients with BDD33. Although this behavior is considered a "self-mutilation", patients with BDD do not have the intention to hurt themselves. Their desire is to improve the skin appearance. They may use pins, knives, clips and blades, commonly causing significant injury with secondary infection or deep scars and, more rarely, causing injury to important vessels such as the carotid artery20. If, according to the patient's perception, the motivation is clearly the complaint related to appearance and improvement of the "defect", then the diagnosis is most likely BDD25.
Likewise, hair concerns are also very common, compelling the patients to seek dermatologic treatment. The most frequent complaints are hair loss and fear of becoming bold (especially men). Many patients report hair thinning, but usually their hair is normal. They may use caps, hairpieces, scarves, and apply hair tonics, or use finasteride and minoxidil. If the complaint is excessive body hair, they may shave, wax, or pluck them. As is the case for skin picking, hair plucking may lead to infection and scars. It is also important to differentiate it from trichotillomania: patients with BDD pluck their hair to improve their appearance, whereas in trichotillomania, hair plucking is not motivated by specific beliefs or thoughts25.
The social, academic or occupational life of most of the patients with BDD is affected as a result of their preoccupations and poor quality of life. The severity of BDD also varies among patients; some lead an apparently normal life despite the suffering and daily losses they experience. In the most severe cases, the patients avoid situations of contact with other people, are not able to work or to have social and affective relationships due to their concern about looking "ugly" or for fear that other people make derogatory comments in relation to their "defect"35. They become aggressive when they are stopped from performing their behaviors or in distressing situations36. In the extremely severe cases, there is risk of suicide4,37.
The levels of criticism of appearance concerns may vary during the course of the disease: some patients show good or reasonable insight, realizing that their preoccupations are rather exaggerated; others do not recognize that these preoccupations are excessive. The separate classification of the "delusional" and "non-delusional" forms is contrary to the clinical experience and to the growing evidence in the literature showing that BDD is a single disorder, and the so-called "delusional" form is merely more severe. Additionally, patients with impaired insight at the beginning of the treatment may show progressive improvement of this aspect.
Few prospective studies analyzing dermatologic and plastic surgery treatments in these patients are available. However, based on clinical observations, patients with BDD, frequently not formally diagnosed with this disease, are characterized by their frequent seek for cosmetic treatments such as laser therapy, dermabrasion, hair treatment and plastic surgeries, even if these treatments are not medically indicated22. Another important clinical aspect is the shame they feel of their symptoms and, consequently, of reporting them to health professionals. Believing that their problem is cosmetic, they seek treatment with specialists in this field.
PREVALENCE OF BODY DYSMORPHIC DISORDER
Body Dysmorphic Disorder in the general population
The prevalence of BDD in the general population is not well established yet. However, it is estimated to affect approximately 1 to 2% of the general population38. Earlier studies reported a prevalence of 0.7% in the general population19, and another showed 1-3%39. More recent studies assessing larger samples indicate a prevalence of 1.7% in Germany and 2.4% in the United States40,41.
In student populations, the prevalences of BDD range from 2.5 to 28%8,19,42. One study showed that there were no significant differences between the samples of American (4%) and German (5.3%)42 students using similar samples and methods.
Body Dysmorphic Disorder in dermatology and plastic surgery populations
Empirical studies suggest that the prevalence of BDD in these patients seems to be higher than in the general population. An American study conducted in 19988 reported that the prevalence of BDD in cosmetic plastic surgery patients seem to range from 7 to 8%, and two European studies showed prevalences of 6.3% and 9.1%43,44.
However, prevalences ranged from 2.9 to 53.6%19 in the literature, although in studies using different methodologies, some with small samples, selection biases and use of non-structured interviews.
The prevalence of BDD in patients seeking clinical dermatology care seems to be slightly higher than in cosmetic surgery populations2,19,20. According to Phillips et al2, dermatologists may be the physicians most often seen by these patients. In a prevalence study in a clinical dermatology population, 14.4% of the patients showed diagnostic criteria for BDD, and most had sought treatment for acne2. BDD seems to be more prevalent among these populations, thus showing the importance for these professionals of the knowledge of this disorder and its clinical aspects.
Body Dysmorphic Disorder in psychiatric patient populations
A study conducted in 199845 showed a 3.2% prevalence of BDD among outpatients of a psychiatry clinic. Fontenelle et al46 found 12% of prevalence in psychiatric outpatients in Brazil. Only two studies investigated BDD in psychiatric patients hospitalized for other diagnoses. They showed that 13 to 16% of the patients had diagnostic criteria for BDD at the moment of the interview or at some point of their lives47. No patient had been diagnosed with BDD during hospitalization, even though some of them considered their BDD symptoms as their "major problem". All patients said that they would not disclose their symptoms spontaneously to their doctor for feeling ashamed.
Body Dysmorphic Disorder in other medical populations
Studies are scarcer in other medical populations. Studies in general internal medicine patients20 and orthodontic patients48 found that 4% and 7.5% of them showed criteria for BDD, respectively. No studies of patients in populations that seek cosmetic treatment with paramedical professionals are available; however, some suggest that patients with BDD frequently seek those professionals28,49. Kittler et al's study50 showed that obese patients may also have BDD and, with the development of bariatric surgery in the past years, there has been a great demand for cosmetic treatments to improve the consequences of drastic weight loss. However, little is known about the psychological aspects of these patients1.
BDD usually starts at adolescence, but may also occur in childhood. On average, patients suffer for up to eleven years until they seek specific treatment20. Phillips et al's extensive study23 showed that in patients with BDD the mean age of development of the disorder was 16.4 years (± 7 years), although appearance dissatisfaction had manifested at 12. 9 years (± 5.8 years). A second incidence peak seems to occur after menoupause10.
Although it is not definitive, there seems to be no differences between genders19. Some studies showed a higher frequency among women19,24, others, among men9,51,52. Rief et al's41 and Koran et al's40 studies had the largest population samples and showed that BDD was slightly more prevalent among women (1.9: 1.4% and 2.5: 2.2%, respectively). However, most of the clinical aspects and demographics seem to be similar between men and women23,27.
In Phillips et al's study27, men were older, single, and preoccupied with their genitals, muscular mass and hair, whereas women were more preoccupied with their breasts, thighs and legs, and also had a greater tendency to camouflage the presumed defect.
Genetics of Body Dysmorphic Disorder
Genetic factors seem to play an important role in the etiology of BDD, as was evidenced by the inheritance patterns observed39. Of the individuals with BDD, 8% have some family member diagnosed with this disorder during life, which represents 4 to 8 times the prevalence in the general population39.
BDD shares inheritance with OCD, as shown in a family study in which 7% of the patients with BDD had some first-degree relative with OCD53.
Abnormal serotonin and dopamine functions may be involved in the development of BDD, as was evidenced by the good response to medications that interfere with the levels of these neurotransmitters in patients with this disorder19. Case reports suggest that the development of BDD may be triggered by inflammatory medical conditions that interfere with the synthesis of serotonin; its symptoms may be exacerbated after streptococcal infection54, or appear following frontotemporal lesion54.
Pathophysiology - theoretical model
Although the pathophysiology of BDD remains unknown, Feusner et al53 observed clinical cases with brain lesion and neuroimaging studies with brain activation that showed patterns of visual perception, distorted body image and emotional processing, and proposed a model for the understanding of the neuroanatomical dysfunctions possibly involved in BDD symptoms. This model proposes the occurrence of a combination of dysfunctions in the frontal-subcortical circuit, hemispheric imbalances, and higher degrees of responses in the amygdala and insula mediating the symptoms and neuropsychological deficits in BDD.
At least two psychological theories were proposed to explain the causes of BDD: the psychoanalytical and the cognitive-behavioral theories. The psychoanalytical theory suggests that BDD emerges from the unconscious displacement of sexual or emotional conflicts, of feelings of inferiority, guilty or distorted body image of some part of the body. Explanations from a cognitive-behavioral point of view suggest that BDD emerges from an interaction between behavioral, cognitive and emotional factors24. The cognitive factors that seem to be instrumental in the development and maintenance of BDD include non realistic attitudes toward the body image related to perfection and symmetry; selective attention to perceived defects and increased monitoring of the presence of appearance defects, in addition to the erroneous interpretation of other's facial expression as being, for instance, of criticism or anger56. Individuals with BDD tend to find that their appearance is much less attractive than what they believe is ideal24.
Most of the patients with BDD have at least one mental disorder as a comorbidity. Comorbidities are very common and, in the largest study on patients with BDD, Gustand and Phillips57 showed that there were diagnostic criteria for more than two other comorbidities throughout life (Axis I / DSM-IV)*. A greater number of comorbidities is associated with greater morbidity and functional impairment57. The most frequent comorbidities seem to be mood and anxiety disorders, obsessive-compulsive spectrum disorders, eating disorders, substance use disorders, and personality disorders58.
Depressive Disorder (MDD) seems to be the most frequent comorbidity. More than 75% of the patients with BDD had at least one episode throughout life and at least half of the patients have criteria for the diagnosis of Current Major Depressive Episode19.
Some authors have suggested that BDD would be a symptom of depression or a disorder related to the spectrum of affective disorders, since both are characterized by low self-esteem, feelings of rejection and uselessness and emotional lability. However, BDD differs from depression mainly because of the presence of obsessive thoughts and compulsive behaviors. Patients with depression are typically less concerned about their appearance and do not focus on any specific aspect of appearance10.
However, like in MDD, patients with BDD are also more prone to suicidal ideation and suicide attempts. In a recent study in which 200 patients with BDD were evaluated, Phillips et al59 reported a frequency of 78% of suicidal ideation and 27.5% of suicide attempts, and BDD was the main motivation reported by the patients.
Anxiety Disorders are common in patients with BDD. In the largest study on comorbidities in patients with BDD, Anxiety Disorders were reported in 60% of the patients throughout their lives15, and Social Phobia had a prevalence of 38%, with a tendency to precede BDD58. Like BDD, Social Phobia is characterized by social anxiety and avoidance behaviors. However, in Social Phobia there is no specific focus on any particular part of the face or body60. Phillips et al61 suggest that Social Phobia develops secondarily in patients with BDD.
Obsessive-Compulsive Spectrum Disorders (OCD spectrum)
BDD has long been related to Obsessive-Compulsive Disorder (OCD) and defined as part of the Obsessive-Compulsive Spectrum Disorders5. Therefore, some considerations on the relationships between BDD and OCD are pertinent.
OCD is a chronic disorder that causes functional impairment characterized by recurrent obsessions and/or compulsive behaviors that are performed to alleviate the discomfort caused by intrusive thoughts. The most common obsessions involve the dimensions of contamination, sexual images, aggression, doubts, order and symmetry. Obsessions are egodystonic, that is, patients with OCD describe their obsessive thoughts as "foreigners" and not derived from their minds, but extrinsically imposed. The most frequent compulsion dimensions involve contamination, washing, checking, order and arrangement, and these obsessions and compulsions are time consuming and contribute to the social impairment and significant distress in the daily life of the patients. Also commonly observed are the avoidance behaviors related to the patient's attempt to evade from situations and things (for instance, objects) that could trigger the symptoms9.
OCD is currently classified as an Anxiety Disorder (DSM-IV), but its reclassification as part of the Obsessive Compulsive Spectrum Disorders is the reason for a debate that has gained importance9.
Hollander et al9 stressed that the studies on familial and neurological comorbidities have evidenced the similarities in the symptoms, course of the disorder, patient population, and neurocircuitry of OCD and Disorders of the OCD Spectrum; they also pointed out to a critical review of the relationships between OCD and Anxiety Disorders. According to these authors, the main reason to classify OCD as an Anxiety Disorder is that anxiety is the core factor in OCD. Obsessions associated with OCD contribute to growing anxiety, and the compulsive behaviors are frequently performed in an attempt to reduce this anxiety. However, anxiety as a symptom is also observed in other psychiatric disorders such as depression and schizophrenia9.
OCD is a clinically heterogeneous disorder (resulting from possibly different phenotypic expressions) and, from the point of view of its dimensions, we can observe an overlapping of symptoms in different disorders of the OCD spectrum.
Hollander et al9 proposed a subdivision of the Obsessive Compulsive Spectrum Disorders into three subgroups:
1) Body image and somatic disorders, characterized by obsessions with the body that include hypochondriasis, eating compulsion, anorexia nervosa, BDD, and depersonalization disorder;
2) Impulse control disorders such as sexual disorders that involve obsessions, compulsions or paraphilias, pathological gambling, trichotillomania, compulsive shopping, Internet abuse, and skin picking. Like in OCD, the patients experience a feeling of tension and emergency associated with these behaviors but, unlike OCD, these behaviors bring a short period of pleasure (which is not present in OCD);
3) Neurobiological disorders with repetitive behaviors such as Tourette Syndrome, Sydenham Chorea, and autism. In these disorders, compulsions are repetitive motor behaviors and usually without obsessions.
Similarities between BDD and OCD have been long recognized. When Morselli identified patients with "body dysmorphic syndrome" (dysmorphophobia) more than one century ago, he noticed the obsessive concerns and compulsive behaviors that characterize these patients62. However, there seems to be a consensus among the authors that, although related to OCD, BDD is not a simple clinical variant of OCD, but they have significant differences10,5,11,62. There is an overlapping between BDD and OCD regarding the age of onset, gender distribution, chronic course, family history of psychiatric disorders and response to treatment.
Frare et al62 pointed out that, from the clinical point of view, the main similarities between BDD and OCD are the preoccupation characteristics, which are obsessive and persistent, with disturbing thoughts that cause anxiety and are hard to resist and control. However, in BDD, the feelings of shame, humiliation, low self-esteem, rejection and reference thoughts are more common. Repetitive behaviors are similar to OCD compulsions.
The characteristics of some symptoms are similar, such as symmetry concerns (regarding the position of objects or the individual's own body), the search for perfection, need to control the environment, frequent reassurance, in addition to checking behaviors. However, the focus of the preoccupations is different between the disorders: in BDD, the physical appearance; and in OCD, fear of contamination or other fears. We also verified differences in relation to checking behaviors (for instance, mirror gazing): in BDD the pattern is more complex (linked to safety) than in the model proposed for OCD (linked to anxiety reduction). These checking behaviors, in fact, seem less effective in reducing anxiety in BDD than in OCD.
The same authors62 point to the main difference between BDD and OCD: the level of insight regarding the symptoms. The preoccupations in BDD are usually experienced in a more natural or egosyntonic fashion (therefore less intrusive), and the patients accept them with some degree of conviction and surrender to them without much resistance.
In OCD, in turn, the preoccupations are usually more egodystonic and, therefore, experienced as more intrusive (irrational, exaggerated); in BDD, many patients are convinced that their perception of the presumed defect is accurate and not distorted. Additionally, many of them also have self-reference ideas, believing that other people are frequently looking at their cosmetic problem. Unlike in OCD, many patients are completely convinced that their perception of the presumed defect is accurate and not distorted, and most of the patients also have reference ideas or delusions. A clinical study showed that in patients with associated OCD and BDD, the level of insight was significantly more impaired in relation to preoccupations with body dysmorphisms than in relation to OCD symptoms8. In addition to the worse insight in BDD, the patients also have a higher predisposition to suicidal ideation and suicide attempts than in OCD63. However, despite these evidences, there are few studies on the similarities and differences between BDD and OCD, as well as on the clinical implications of the association between these disorders.
BDD has a high comorbidity with the disorders of the OCD Spectrum, and the frequency of association with OCD ranges from 30%57 to 78%15 throughout life. Some aspects of BDD also overlap with other disorders of the OCD Spectrum, such as trichotillomania63 and skin picking64.
Substance Use and Abuse
Several studies report high rates of substance abuse in patients with BDD10,57. Grant and Phillips26 reported abuse in 48.9% (n = 86) and dependence in 35.8%, particularly on alcohol (29%). In 68% of these patients, BDD was the main causal element related to substance abuse.
Eating Disorders seem relatively common in individuals with BDD. Some authors suggested that the distorted body image may be the main aspect of the disease both in BDD and in Eating Disorders. Ruffolo et al32 found an incidence of 32.5% of Eating Disorders (Anorexia Nervosa, Bulimia Nervosa and other non specified Eating Disorders) throughout the life of patients with BDD. The authors compared the groups with and without Eating Disorders and showed that comorbid patients were more frequently women, and they had more significant dissatisfaction and disturbances with their body image than patients with BDD alone.
There seems to be a high prevalence of Personality Disorders among patients with BDD. In a study on Axis II comorbidities, 57% of the patients with BDD had diagnostic criteria for at least one Personality Disorder, more frequently the avoidance type19. Paranoid, obsessive-compulsive, and dependent personalities may also occur with BDD19.
BDD shows better response to selective serotonin-reuptake inhibitors (SSRI), but also responds to tricyclic antidepressants. A retrospective study by Hollander et al in Pavan et al10 showed better remission of symptoms of BDD when fluoxetine, fluvoxamine or clomipramine were used. A double-blind study conducted by Phillips65 compared fluoxetine to placebo and confirmed the efficacy of fluoxetine in the treatment of BDD. In another study, the authors suggest the need to observe protocols in order to find adequate therapeutic doses64, since the doses were considered minimally adequate for BDD in only 34.4% of the patients. Phillips66 showed good therapeutic efficacy with citalopram, but drug discontinuation led to recurrence of symptoms in 83.3% of the patients within 38 weeks. These studies showed that the presence of delusional characteristics do not seem to be predictive of a poor response to treatment with SSRI. The patients responded to treatment with reduction in preoccupations, a decrease in stress, a reduction in behavioral ritual, and significant improvement in social and occupational functioning. The defect is generally noted (it rarely is no longer perceived), but usually causes less distress10.
The efficacy of the cognitive-behavioral therapy (CBT) for BDD has been confirmed with randomized studies and controlled clinical trials19. It involves the identification and modification of cognitions and "problem" behaviors related to appearance. The strategies used in BDD include self-monitoring of thoughts and behaviors related to appearance (for instance: control of the time spent in mirror checking); cognitive techniques (for instance: by defying thoughts of the appearance); and behavioral exercises (for instance: exposing the patient to situations of fear and preventing engagement in compulsive behaviors)67,68.
No studies with a strict evaluation of the combination of psychological and pharmacological treatments of BDD are yet available.
According to Phillips and Dufresne69, in recent years BDD has gone from being a neglected psychiatric disorder to one that has been better recognized and understood. It is a relatively common and severe disorder that often presents to mental health professionals and also non-psychiatrist physicians. Many patients feel ashamed of their symptoms and do not report them, even if they wish that their physician knows about their appearance concerns3. On average, the patients seek specific treatment eleven years after the onset of the first symptoms3.
BDD has probably been underestimated, because few psychiatrists or specialists who make the first contact with patients with BDD are able to recognize this condition10. In contrast, patients with BDD seek dermatologists, plastic surgeons and other professionals in order to enhance their appearance, but are dissatisfied with the results and demand new interventions for the same complaint or for another part of the body to which they transferred their focus of attention. It is of the utmost importance that these professionals recognize the symptoms of BDD and specifically investigate them. Cosmetic treatments seem inefficacious in BDD and may offer risks to the physicians who perform them, since the patients may become aggressive and violent with these professionals. Additionally, these patients have higher rates of suicidal ideation and suicide attempts, including effective ones.
It also seems fundamental that dermatologists be trained to identify subclinical cases or patients with complaints signaling the presence of BDD, because they are in a strategic position to recognize the patients' symptoms and thus refer them to appropriate treatment. It is difficult to refer these patients to the psychiatrist since, due to their impaired insight, these patients do not recognize that their perception of the defect is distorted, and that their appearance concerns are attributable to a psychiatric disorder.
1. Sarwer DB, Crerand CE. Body dysmorphic disorder and appearance enhancing medical treatments. Body Image. 2008;5:50-8. [ Links ]
2. Phillips KA, Dufresne RG Jr, Wilkel CS, Vittorio CC. Rate of body dysmorphic disorder in dermatology patients. J Am Acad Dermatol. 2000;42:436-41. [ Links ]
3. Phillips KA. The broken mirror: understanding and treating Body Dysmorphic Disorder. New York: Oxford University Press, 1996. [ Links ]
4. Sarwer DB, Crerand CE, Didie ER. Body dysmorphic disorder in cosmetic surgery patients. Facial Plast Surg. 2003;19:7-18. [ Links ]
5. Phillips KA, Kaye WH. The relationship of body dysmorphic disorder and eating disorders to obsessive-compulsive disorder. CNS Spectr. 2007;12:347-58. [ Links ]
6. Edgerton MT, Jacobson WE, Meyer E. Surgicalpsychiatricr study of patients seeking plastic (cosmetic) surgery: ninety-eight consecutive patients with minimal deformity. Br J Plast Surg. 1960;13:136-45. [ Links ]
7. Cotterill JA. Body dysmorphic disorder. Dermatol Clin. 1996;14:457-63. [ Links ]
8. Sarwer DB, Wadden TA, Pertschuk MJ, Whitaker LA. Body image dissatisfaction and body dysmorphic disorder in 100 cosmetic surgery patients. Plast Reconstr Surg. 1998;101:1644-9. [ Links ]
9. Hollander E, Neville D, Frenkel M, Josephson S, Liebowitz MR. Body dysmorphic disorder. Diagnostic issues and related disorders. Psychosomatics. 1992;33:156-65. [ Links ]
10. Pavan C, Simonato P, Marini M, Mazzoleni F, Pavan L, Vindigni V. Psychopathologic aspects of body dysmorphic disorder: a literature review. Aesthetic Plast Surg. 2008;32:473-84. [ Links ]
11. Perugi G, Akiskal HS, Giannotti D, Frare F, Di Vaio S, Cassano GB. Gender-related differences in body dysmorphic disorder (dysmorphophobia). J Nerv Ment Dis. 1997;185:578-82. [ Links ]
12. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 3rd ed. Washington, D.C.: American Psychiatric Association, 1980. [ Links ]
13. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 3rd ed. revised. 1987. [ Links ]
14. American Psychiatric Association. Diagnostic and statistical manual of mental disorders (DSM-IV). 4th ed. Washington (DC): American Psychiatric Association, 1994. [ Links ]
15. Simeon D, Hollander E, Stein DJ, Cohen L, Aronowitz B. Body dysmorphic disorder in the DSM-IV field trial for obsessive-compulsive disorder. Am J Psychiatry. 1995;152:1207-9. [ Links ]
16. Hounie AG, Pauls DL, Mercadante MT, Rosario-Campos MC, Shavitt RG, de Mathis MA, et al. Obsessivecompulsive spectrum disorders in rheumatic fever with and without Sydenham's chorea. J Clin Psychiatry. 2004;65:994-9. [ Links ]
17. Castle DJ, Phillips KA. Obsessive-compulsive spectrum of disorders: a defensible construct? Aust N Z J Psychiatry. 2006;40:114-20. [ Links ]
18. Phillips KA, McElroy SL, Hudson JI, Pope HG Jr. Body dysmorphic disorder: an obsessive-compulsive spectrum disorder, a form of affective spectrum disorder, or both? J Clin Psychiatry. 1995;56 Suppl 4:41-51; discussion 52. [ Links ]
19. Crerand CE, Franklin ME, Sarwer DB. Body dysmorphic disorder and cosmetic surgery. Plast Reconstr Surg. 2006;118:167e-80e. [ Links ]
20. Phillips KA. The Presentation of Body Dysmorphic Disorder in Medical Settings. Prim Psychiatry. 2006;13:51-9. [ Links ]
21. World Health Organization. International Classification of Mental and Behavioural Disorders. Tenth revision (ICD 10) Geneva: WHO, 1992. [ Links ]
22. Castle DJ, Rossell S, Kyrios M. Body dysmorphic disorder. Psychiatr Clin North Am. 2006;29:521-38. [ Links ]
23. Phillips KA, Menard W, Fay C, Weisberg R. Demographic characteristics, phenomenology, comorbidity, and family history in 200 individuals with body dysmorphic disorder. Psychosomatics. 2005;46:317-25. [ Links ]
24. Veale D. Advances in a cognitive behavioural model of body dysmorphic disorder. Body Image. 2004;1:113-25. [ Links ]
25. Castle DJ, Phillips KA, Dufresne RG Jr. Body dysmorphic disorder and cosmetic dermatology: more than skin deep. J Cosmet Dermatol. 2004;3:99-103. [ Links ]
26. Grant JE, Phillips KA. Recognizing and treating body dysmorphic disorder. Ann Clin Psychiatry. 2005;17:205-10. [ Links ]
27. Phillips KA, Menard W, Fay C. Gender similarities and differences in 200 individuals with body dysmorphic disorder. Compr Psychiatry. 2006;47:77-87. [ Links ]
28. Crerand CE, Phillips KA, Menard W, Fay C. Nonpsychiatric medical treatment of body dysmorphic disorder. Psychosomatics. 2005;46:549-55. [ Links ]
29. Phillips KA, Dufresne RG. Body dysmorphic disorder. A guide for dermatologists and cosmetic surgeons. Am J Clin Dermatol. 2000;1:235-43. [ Links ]
30. Hunter-Yates J, Dufresne RG Jr, Phillips KA. Tanning in body dysmorphic disorder. J Am Acad Dermatol. 2007;56(5 Suppl):S107-9. [ Links ]
31. Pope CG, Pope HG, Menard W, Fay C, Olivardia R, Phillips KA. Clinical features of muscle dysmorphia among males with body dysmorphic disorder. Body Image. 2005;2:395-400. [ Links ]
32. Ruffolo JS, Phillips KA, Menard W, Fay C, Weisberg RB. Comorbidity of body dysmorphic disorder and eating disorders: severity of psychopathology and body image disturbance. Int J Eat Disord. 2006;39:11-9. [ Links ]
33. Grant JE, Menard W, Phillips KA. Pathological skin picking in individuals with body dysmorphic disorder. Gen Hosp Psychiatry. 2006;28:487-93. [ Links ]
34. Hollander E, Kim S, Khanna S, Pallanti S. Obsessivecompulsive disorder and obsessive-compulsive spectrum disorders: diagnostic and dimensional issues. CNS Spectr. 2007;12(2 Suppl 3):5-13. [ Links ]
35. Buhlmann U, Cook LM, Fama JM, Wilhelm S. Perceived teasing experiences in body dysmorphic disorder. Body Image. 2007;4:381-5. [ Links ]
36. Phillips KA. Psychosis in body dysmorphic disorder. J Psychiatr Res. 2004;38:63-72. [ Links ]
37. Marazziti D, Giannotti D, Catena MC, Carlini M, Dell'Osso B, Presta S, et al. Insight in body dysmorphic disorder with and without comorbid obsessivecompulsive disorder. CNS Spectr. 2006;11:494-8. [ Links ]
38. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, D.C.: American Psychiatric Association, 2000. [ Links ]
39. Bienvenu OJ, Samuels JF, Riddle MA, Hoehn-Saric R, Liang KY, Cullen BA, et al. The relationship of obsessivecompulsive disorder to possible spectrum disorders: results from a family study. Biol Psychiatry. 2000;48:287-93. [ Links ]
40. Koran LM, Abujaoude E, Large MD, Serpe RT. The prevalence of body dysmorphic disorder in the United States adult population. CNS Spectr. 2008;13:316-22. [ Links ]
41. Rief W, Buhlmann U, Wilhelm S, Borkenhagen A, Brahler E. The prevalence of body dysmorphic disorder: a population-based survey. Psychol Med. 2006;36:877-85. [ Links ]
42. Bohne A, Wilhelm S, Keuthen NJ, Florin I, Baer L, Jenike MA. Prevalence of body dysmorphic disorder in a German college student sample. Psychiatry Res. 2002;109:101-4. [ Links ]
43. Altamura C, Paluello MM, Mundo E, Medda S, Mannu P. Clinical and subclinical body dysmorphic disorder. Eur Arch Psychiatry Clin Neurosci. 2001;251:105-8. [ Links ]
44. Aouizerate B, Pujol H, Grabot D, Faytout M, Suire K, Braud C, et al. Body dysmorphic disorder in a sample of cosmetic surgery applicants. Eur Psychiatry. 2003;18:365-8. [ Links ]
45. Zimmerman M, Mattia JI. Body dysmorphic disorder in psychiatric outpatients: recognition, prevalence, comorbidity, demographic, and clinical correlates. Compr Psychiatry. 1998;39:265-70. [ Links ]
46. Fontenelle LF, Telles LL, Nazar BP, de Menezes GB, do Nascimento AL, Mendlowicz MV, et al. A sociodemographic, phenomenological, and long-term follow-up study of patients with body dysmorphic disorder in Brazil. Int J Psychiatry Med. 2006;36:243-59. [ Links ]
47. Conroy M, Menard W, Fleming-Ives K, Modha P, Cerullo H, Phillips KA. Prevalence and clinical characteristics of body dysmorphic disorder in an adult inpatient setting. Gen Hosp Psychiatry. 2008;30:67-72. [ Links ]
48. Hepburn S, Cunningham S. Body dysmorphic disorder in adult orthodontic patients. Am J Orthod Dentofacial Orthop. 2006;130:569-74. [ Links ]
49. Tignol J, Biraben-Gotzamanis L, Martin-Guehl C, Grabot D, Aouizerate B. Body dysmorphic disorder and cosmetic surgery: evolution of 24 subjects with a minimal defect in appearance 5 years after their request for cosmetic surgery. Eur Psychiatry. 2007;22:520-4. [ Links ]
50. Kittler JE, Menard W, Phillips KA. Weight concerns in individuals with body dysmorphic disorder. Eat Behav. 2007;8:115-20. [ Links ]
51. Ishigooka J, Iwao M, Suzuki M, Fukuyama Y, Murasaki M, Miura S. Demographic features of patients seeking cosmetic surgery. Psychiatry Clin Neurosci. 1998; 52:283-7. [ Links ]
52. Taqui AM, Shaikh M, Gowani SA, Shahid F, Khan A, Tayyeb SM, et al. Body Dysmorphic Disorder: gender differences and prevalence in a Pakistani medical student population. BMC Psychiatry. 2008;8:20. [ Links ]
53. Feusner JD, Yaryura-Tobias J, Saxena S. The pathophysiology of body dysmorphic disorder. Body Image. 2008;5:3-12. [ Links ]
54. Mathew SJ. PANDAS variant and body dysmorphic disorder. Am J Psychiatry. 2001;158:963. [ Links ]
55. Gabbay V, Asnis GM, Bello JA, Alonso CM, Serras SJ, O;Dowd MA. New onset of body dysmorphic disorder following frontotemporal lesion. Neurology. 2003;61:123-5. [ Links ]
56. Buhlmann U, McNally RJ, Wilhelm S, Florin I. Selective processing of emotional information in body dysmorphic disorder. J Anxiety Disord. 2002;16:289-98. [ Links ]
57. Gunstad J, Phillips KA. Axis I comorbidity in body dysmorphic disorder. Compr Psychiatry. 2003;44:270-6. [ Links ]
58. Bellino S, Zizza M, Paradiso E, Rivarossa A, Fulcheri M, Bogetto F. Dysmorphic concern symptoms and personality disorders: a clinical investigation in patients seeking cosmetic surgery. Psychiatry Res. 2006;144:73-8. [ Links ]
59. Phillips KA, Didie ER, Menard W. Clinical features and correlates of major depressive disorder in individuals with body dysmorphic disorder. J Affect Disord. 2007;97:129-35. [ Links ]
60. Pinto A, Phillips KA. Social anxiety in body dysmorphic disorder. Body Image. 2005;2:401-5. [ Links ]
61. Phillips KA, Pinto A, Jain S. Self-esteem in body dysmorphic disorder. Body Image. 2004;1:385-90. [ Links ]
62. Frare F, Perugi G, Ruffolo G, Toni C. Obsessive-compulsive disorder and body dysmorphic disorder: a comparison of clinical features. Eur Psychiatry. 2004;19:292-8. [ Links ]
63. Phillips KA, Pinto A, Menard W, Eisen JL, Mancebo M, Rasmussen SA. Obsessive-compulsive disorder versus body dysmorphic disorder: a comparison study of two possibly related disorders. Depress Anxiety. 2007;24:399-409. [ Links ]
64. Phillips KA, Pagano ME, Menard W. Pharmacotherapy for body dysmorphic disorder: treatment received and illness severity. Ann Clin Psychiatry. 2006;18:251-7. [ Links ]
65. Phillips KA. Placebo-controlled study of pimozide augmentation of fluoxetine in body dysmorphic disorder. Am J Psychiatry. 2005;162:377-9. [ Links ]
66. Phillips KA. An open-label study of escitalopram in body dysmorphic disorder. Int Clin Psychopharmacol. 2006;21:177-9. [ Links ]
67. Neziroglu F, Cash TF. Body dysmorphic disorder: causes, characteristics, and clinical treatments. Body Image. 2008;5:1-2. [ Links ]
68. Buhlmann U, Reese HE, Renaud S, Wilhelm S. Clinical considerations for the treatment of body dysmorphic disorder with cognitive-behavioral therapy. Body Image. 2008;5:39-49. [ Links ]
69. Phillips KA, Dufresne RG. Body dysmorphic disorder. A guide for dermatologists and cosmetic surgeons. Am J Clin Dermatol. 2000;1:235-43. [ Links ]
Mailing Address: Conflicts of interest: None. * Study conducted
at the University of Sao Paulo School of Medicine (FMUSP) Sao Paulo (SP),
Luciana Archetti Conrado
Av. Pavão, 955 - CJ. 47/48 - Moema
04516 012 São Paulo SP
Financial Support: None.
Conflicts of interest: None.
* Study conducted at the University of Sao Paulo School of Medicine (FMUSP) Sao Paulo (SP), Brazil.