 Magazine
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Body Dysmorphic
Disorder Body dysmorphic disorder is an under-recognised chronic problem that is defined as an excessive preoccupation with an imagined or a minor defect of a localised facial feature or body part, resulting in decreased social, academic and occupational functioning. Patients who have body dysmorphic disorder are preoccupied with an ideal body image and view themselves as ugly or misshapen. Comorbid psychiatric disorders may also be present in these patients. Body dysmorphic disorder is distinguished from eating disorders such as anorexia nervosa that encompass a preoccupation with overall body shape and weight. Psychosocial and neurochemical factors, specifically serotonin dysfunction, are postulated etiologies. Treatment approaches include cognitive-behavioural hypnotherapy, psychotherapy and psychotropic medication. To relieve the symptoms of body dysmorphic disorder, selective serotonin reuptake inhibitors, in higher dosages than those typically recommended for other psychiatric disorders, may be necessary.
BDD is a chronic disorder that is equally common in men and women, and usually presents during adolescence and young adulthood. The average age of onset is 17 years. Persons who have BDD are most often concerned with the following: skin imperfections, such as wrinkles, scars, acne and blemishes; hair (head or body hair, too much or too little); and facial features (e.g., a misshapen nose, overall shape, genital size and symmetry of a feature). Such persons are preoccupied with their perceived "gross imperfection(s)" and may ask their GP to correct the perceived defect, or they may seek referral to a dermatologist or plastic surgeon. In a British study 62 percent of patients with BDD had discussed their symptoms with their GP. Of the patients in the study, 48 percent had seen a cosmetic surgeon or dermatologist at least once, and 26 percent had undergone at least one operations About 2 to 7 percent of persons who have undergone plastic surgery may have BDD Young people with body dysmorphic disorder (BDD) worry about some aspect of their appearance. They worry, for example, that they have pimples or that their skin is scarred or bumpy, their nose is too big, they are fat or too thin. Or they may think something else is wrong with how they look. When others tell them that they look fine or that the flaw they perceive is minimal (or non-existent), young people with this disorder find it hard to believe this reassurance.
Adolescents with BDD think a lot about their perceived physical flaw, generally for at least an hour a day. Some say they're obsessed. Most find that they don't have as much control over their thoughts about the body flaw as they would like.
In addition, the appearance concern causes significant distress (for example, anxiety or depression) or it causes significant problems in functioning. Although some young people with this disorder manage to function well despite their distress, many find that their appearance concerns cause problems for them. For example, they may find it hard to concentrate on their job or schoolwork, which may suffer, and relationship problems are common. Adolescents with BDD may have few friends, avoid dating, and feel very self-conscious in social situations.
Obsessive mirror checking may seem normal for teens in their formative years, but is the image some see causing severe angst-even causing some to contemplate suicide? "These adolescents have a very distorted view of how they look, and it does not match how others may see them," Teens plagued with BDD. are obsessed with negative perceptions of their bodies. Many times they end up dropping out of school, suffering major depressive episodes, avoiding most social contact, and even attempting suicide in some cases. BDD. can be a devastating disorder for adolescents, and it is thought to be caused by a chemical imbalance in the brain. Sometimes use of drugs such as ecstasy may be associated with the onset
The severity of BDD. varies. Some sufferers experience manageable distress and are able to function well, although not up to their potential. Others find that this disorder ruins their life. BDD. also has some features that, while not necessary for the diagnosis, can provide clues to its presence, some of which are the following:
Some clues to the presence of BDD:-- Frequently comparing one's appearance with that of others, or scrutinising the appearance of others; Often checking how one looks in the mirror: camouflaging the perceived defect with clothing, makeup, a hat or a hand, or changing one's posture, often this can draw attention to the perceived defect convincing the sufferer of the offensiveness of its appearance. Seeking surgery, dermatological treatment, or other medical treatment for appearance concerns when doctors, parents, or peers have said such treatment is unnecessary; Constantly seeking reassurance about the perceived flaw or attempting to convince others of its repulsiveness; Excessive grooming (combing one's hair, shaving over and over, removing or cutting hair, applying heavy makeup or cover-up creams); picking at one's skin or squeezing pimples/blackheads for hours, avoiding mirrors, Exercising or dieting excessively; Frequently touching the perceived defect, measuring the "unpleasant" body part; excessively reading about the supposed defective body part, avoiding social situations. . in which the perceived defect might be exposed; and feeling very anxious and self- . . conscious around peers because of the perceived defect
BDD is often underdiagnosed
The diagnosis of BDD is often missed because of trivialisation. BDD is easily trivialised, even though it is a serious and distressing condition, secrecy and shame: many adolescents with BDD don't reveal their symptoms to others because of embarrassment. · Lack of familiarity with BDD: many health professionals, including primary healthcare providers, are not aware that BDD is a known psychiatric disorder that often responds to psychiatric treatment; or pursuit of non-psychiatric, medical, and surgical treatment: many young people with BDD see dermatologists, plastic surgeons, and other physicians rather than mental health professionals. These treatments often are not helpful.
BDD can be misdiagnosed
BDD is often misdiagnosed as a different psychiatric disorder. This occurs because BDD can produce symptoms that mimic other disorders such as social phobia, agoraphobia, panic disorder, trichotillomania (excessive hair pulling), obsessive-compulsive disorder, and depression.
Hope for BDD sufferers
Psychiatric treatment is often effective in decreasing BDD symptoms and the suffering they cause. The treatments that appear most effective are certain medications, namely the selective serotonin reuptake inhibitors (SSRI s), and cognitive behavioural therapy.
The prescription-only SSRIs are not addicting and are usually well tolerated. They can significantly relieve BDD symptoms by diminishing bodily preoccupation, distress, depression, and anxiety and by significantly allowing increased control over the persons thoughts and improving functioning. In some cases these medications are lifesaving, especially for those who have attempted suicide in their despair over their appearance.
During cognitive-behavioural therapy the specially trained therapist helps the person with BDD resist compulsive behaviours-for example, mirror checking-and face avoided situations like social situations. It's important to determine whether a therapist has been specifically trained in cognitive-behavioural therapy. Some other types of talk therapy do not appear to be effective for BDD.
Whether by means of television, newspapers or magazines, we are constantly presented with images of perfect faces and bodies. While maturing in such an environment, the impressionable adolescent develops a mental image of how the ideal man or woman should appear. Persons who become preoccupied with perfection often view themselves as imperfect and may develop a distorted picture of their own body and face. This perception can lead to unhealthy behaviours such as eating disorders and body dysmorphic disorder (BDD). Often, the primary care physician has the first opportunity to intervene with these patients.
Definitions and Etiology
Body image is defined as a mental picture of the size, shape and form of our body. It also describes our feelings about these physical characteristics. Body image is divided into the following two components: how we perceive the appearance of our body and our attitude toward our body. A significantly distorted perception of the body may lead to self-destructive behaviours aimed at improving the appearance of the body.
Three areas of concern involve body image distortion: neurologic disorders, in which patients exhibit a perception of their body (e.g., in neglect syndromes); eating disorders; and BDD. Patients with BDD have an excessive preoccupation with a slight or imagined defect of a specific body part that results in impaired social, academic or occupational functioning. BDD must be distinguished from eating disorders such as anorexia nervosa that involve a preoccupation with overall body shape and weight.
The proposed etiologies of BDD are primarily represented by psychological and neurochemical hypotheses. Factors that may predispose persons to BDD include low self-esteem, critical parents and significant others, early childhood trauma and unconscious displacement of emotional conflict. Patients seem to be at least partially responsive to medications that increase serotonin levels, indicating that neurochemical factors may include lower levels of serotonin..
Illustrative Cases
Lengthening or shortening of leg bone Plastic surgery Breast and other implants Liposuction Botulnium toxin injections (Botox) Steroids Self mutilation (DIY amputations)
Clinical Manifestations Subsyndromal BDD occurs when patients have an excessive preoccupation with a particular feature, but they have not yet sought help to fix the perceived defect and their social, academic or occupational functioning has not yet been affected. Subsyndromal presentations of BDD may occur but, as yet, no cases or studies have reported the frequency of subsyndromal BDD.
Persons who have BDD spend many hours focusing on their physical features and engaging in repetitive and time-consuming behaviours, resulting in decreased social, academic and occupational functioning. They tend to avoid social interaction, spend countless hours checking their features in reflective surfaces, discover ways to camouflage the perceived defect, constantly seek reassurance from others that their defect is indeed present or is not so bad, and develop grooming behaviours to make the defect more presentable. Many are unable to stay in school, to maintain significant relationships or to keep steady jobs. Some may go so far as suicide. In a study of 100 patients with BDD, nearly one half had been hospitalised for a psychiatric condition, and 30 percent had made at least one suicide attempt Some persons with BDD realise that their concerns may be exaggerated, while others simply do not.
Diagnostic Criteria for Body Dysmorphic Disorder:
Approximately 50 percent of patients with BDD meet these criteria
Preoccupation with an imagined defect in appearance. If a slight physical anomaly is present, the person's concern is markedly excessive. The preoccupation causes clinically significant distress or impairment in social, occupational or other important areas of functioning. The preoccupation is not better accounted for by another mental disorder (e.g.,dissatisfaction with overall body shape and size in anorexia nervosa).
Treatment
Treatment approaches to BDD involve the use of therapeutic agents, principally selective serotonin reuptake inhibitors (SSRIs) and cognitive-behavioural psychotherapy. Three retrospective studies demonstrated improvement of BDD with the use of SSRIs. These results lead to speculation that the etiology of BDD is related to poor regulation and depletion of serotonin, although altered serotonin physiology may be either a consequence or a marker of this disorder. Two prospective studies that used open-label SSRIs demonstrated clinical efficacy, including decreased preoccupation with the perceived defect, decreased ritualistic behaviour, improved insight, and improved social, academic and occupation functioning.'
Dosages of SSRIs may need to be higher than those typically recommended for eating disorders. For resolution of BDD., suggested dosages of SSRIs include the following ranges: fluvoxamine (Luvox), 200 to 250 mg per day; fluoxetine (Prozac), 40 to 80 mg per day; paroxetine (Paxil), 40 to 60 mg per day; or sertraline (Zoloft), 100 to 200 mg per day. Neuroleptics alone may not cure BDD but may be useful adjuncts to SSRIs in alleviating symptoms of BDD that are unresponsive to SSRIs alone.
Disorders That Often Accompany Body Dysmorphic Disorder
Because BDD by definition involves an "irrational" belief or conviction associated with considerable obsessiveness and anxiety, cognitive-behavioural psychotherapy may be beneficial. The false belief and obsession may respond to cognitive therapy. Aberrant social interaction and coexisting anxiety may respond to behavioural intervention.
Cognitive-behavioural techniques were used in the situation and with imagery with response prevention to improve the symptoms of BDD in a study of 10 patients.25 In this study, all 10 patients responded favourably to a six-week treatment program.
In another study, hypnotherapy, thought stopping and relaxation resulted in significant clinical improvement in 22 of 27. Hypnotherapy affords quicker results the modern techniques applied assist with correcting the hallucinations of body defects. Other patients with BDD who were treated with two-hour sessions per week of cognitive-behavioural therapy over eight weeks obtaining similar results. Psychiatric conditions that may complicate BDD include depression, anxiety and obsessive-compulsive disorder. Conventional and combination of conventional and complementary therapies can help with these conditions, but it is crucial that the condition has been medically diagnosed and the competence of the complementary therapist ascertained.
Skin disorders, weight problems, anxiety, confidence issues and low esteem are all conditions that lend themselves well to treatment with hypnosis, as the person with the perceived problem can not always put what they are experiencing into words, what they are experience is not necessarily experienced on a verbal level. This of course has advantages over other talking therapies. Given the secrecy that surrounds the condition patients do not have to reveal any thing that they perceive too embarrassing or what they feel leaves them open to ridicule.
Clinical Implications in Primary Care
Awareness of BDD may assist the family GP in early detection. Patients may visit a family doctor to seek referral to a dermatologist or plastic surgeon to remedy a perceived defect when none is actually present. The family doctor then has an opportunity to discuss the situation. These patients are highly anxious, and the first step in the discussion should be validation of the patient's concern. Next, the physician should seek additional information to determine the severity of the disorder. A discussion about how much time and worry is devoted to the perceived defect will help. The physician should also ask what the patient has done to remedy the defect, and how the defect has altered the patient's social, academic or occupational activities
Once the family doctor is convinced that the patient has BDD, treatment options may be discussed in a positive way. Treatment may require normal or higher-than-normal dosages of an SSRI for at least a three-month trial period. If one SSRI is ineffective, another may be tried with success
The potential benefits of psychiatric or psychosocial referral may be discussed, although the family doctor should not insist on referral because these patients may subsequently be lost to follow-up.
Body Dysmorphic Disorder
Maurice Sterndale
D Hyp. PDCHyp. is a clinical hypnotherapist in the UK, working in the
Oldham, Lancashire area. He is a: Web: www.maurice-sterndale.com
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