Flaw management: A brief psychological overview of Body Dysmorphic Disorder

Over the last few years, Body Dysmorphic Disorder (BDD) has become the focus of increasing media attention particularly in relation to being cited as one of the main reasons why people seek out cosmetic surgery, as well as being implicated in a wide variety of diverse medical and/or psychiatric conditions including people with eating disorders, obsessive-compulsive disorders, and apotemnophilia (i.e., the desire to be an amputee).

At its simplest level, BDD is a distressing, handicapping, and/or impairing preoccupation with an imagined or slight defect in body appearance that the sufferer perceives to be ugly, unattractive, and/or deformed (hence the recent upsurge in relation to those with an insistent desire for plastic surgery). BDD sufferers can think about their perceived defect for hours and hours every day. Other BDD sufferers may indeed have a minor physical abnormality, but the concern attached to it is regarded as grossly excessive. There are hundreds of published papers on BDD but most of this article is based on the writings and reviews of Dr Katharine Phillips (Professor of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University, USA) and the British psychiatrist Dr David Veale (The Priory Hospital North London).

People with BDD have been written about for more than 100 years and there has been a large increase in research into BDD over the last two decades. Like pathological gambling, the criteria for BDD changed quite radically between the publication of the American Psychiatric Association’s DSM-III (1980), and DSM-IV (1994). Until relatively recently, BDD used to be called ‘’dysmorphophobia’. In the DSM-III, BDD didn’t have any specified diagnostic criteria and was only mentioned as an example of an atypical somatoform disorder. In the revise edition of the DSM-III (1987), BDD became a separate disorder in the somatoform section. Subtle changes were then made to the DSM-IV criteria.

Arguably the most notable change was that the distinction between ‘delusional’ and ‘non-delusional’ BDD was diminished due to empirical evidence showing that the delusional and non-delusional variants of BDD may be variants of the same disorder (it should also be noted that in the World Health Organization’s International Classification Diseases (ICD-10), BDD is classified as a type of hypochondriacal disorder along with hypochondriasis, in the somatoform section). There is frequent comorbidity in BDD (e.g., social phobia, depression, suicidal ideation, and obsessive-compulsive disorder). In fact, almost all BDD sufferers engage in at least one compulsive behaviour such as compulsive checking of mirrors, excessive grooming and make-up application, excessive exercise, repeatedly asking other people how they look, compulsive buying of beauty products, and persistent seeking of cosmetic surgery. These behaviours can become potentially all encompassing and consuming, and like many addictive behaviours become unpleasurable and typically difficult to control or resist. The current DSM-IV diagnostic criteria for body dysmorphic disorder are that there is:

• Preoccupation with an imagined defect in appearance. If a slight physical anomaly is present, the person’s concern in 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 body shape and size in Anorexia Nervosa)

Dr David Veale notes that among BDD sufferers, any body part may be the preoccupying focus. However, research has indicated that most BDDs involve skin, hair, or facial features (e.g., eyes, nose, lips) that the sufferer feels is flawed (e.g., acne), out of proportion and/or asymmetric. Research has also shown that the pre-occupying focus can change over time. Dr Veale speculates that this changing focus may explain why some people are never happy after cosmetic surgery procedures. Sufferers may repeatedly examine the ‘‘defect’’ that for some may become obsessive and/or compulsive.

A couple of empirical studies have reported the prevalence of BDD as 0.7% in the general population. The prevalence rate among other specific groups – such as adolescents and young adults – tend to be a little higher, and among some groups it is significantly higher. For instance, much higher prevalence rates of BDD have been reported among people wanting plastic surgery (5%) and among dermatology patients (12%).

Dr Veale notes there are very limited data on the risk factors associated with the development of BDD. Furthermore, those factors that have been associated with BDD may not be unique or specific to BDD (for instance, risk factors such as poor peer relationships, social isolation, lack of support in the family, and/or sexual abuse). Risk factors identified in BDD include:

• Genetic predispositions;
• Shyness, perfectionism, or an anxious temperament;
• Childhood adversity (e.g., teasing or bullying about appearance)
• A history of dermatological or other as an adolescent (e.g., acne) that has since been resolved.
• Being more aesthetically sensitive than average
• Greater aesthetic perceptual skills, manifested in their education or training in art and design.

Although there are various worldwide case studies, most published studies on BDD comprise people from Westernized societies. Dr Katharine Phillips and her colleagues claim there are no studies that have directly compared BDD’s clinical features across different countries or cultures but concluded that BDD studies from around highlighted there were more similarities than differences. Dr Phillips says that men and women had many similarities in these studies (demographic and clinical characteristics). She has also reported that both male and female BDD sufferers are equally likely to seek and receive dermatological and cosmetic treatment.

Dr Veale claims that although there are broad similarities between the genders there are some gender differences. For instance, men with BDD show a greater preoccupation with their genitals, and women with BDD are more likely to have a co-morbid eating disorder. Perhaps somewhat predictably, female BDD sufferers have a greater preoccupation with weight, hips, breasts, legs, and excessive body hair. They are also more likely than BDD males to conceal perceived defects with make-up, to check mirrors, and to pick at their skin. Male BDD sufferers have a greater preoccupation with muscle dysmorphia, and thinning hair. Compared to females, BDD males are more likely to be single, and have a substance-related disorder.

The most recent review by Dr Phillips and her colleagues concluded that: “Much more research is needed on all aspects of BDD. Advances in knowledge will likely lead to future refinements of this disorder’s diagnostic criteria and an increased understanding of the relationship between BDD’s delusional and non-delusional forms as well as BDD’s relationship to other psychiatric disorders”.

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Didie, E.R., Kuniega-Pietrzak, T., Phillips, K.A. (2010). Body image in patients with body dysmorphic disorder: evaluations of and investment in appearance, health/illness, and fitness. Body Image, 7, 66–69.

Kelly, M.M., Walters, C. & Phillips, K.A. (2010). Social anxiety and its relationship to functional impairment in body dysmorphic disorder. Behavor Therapy, 41, 143-153.

Mancuso, S., Knoesen, N. & Castle, D.J. (2010). Delusional vs nondelusional body dysmorphic disorder. Comprehensive Psychiatry, 51, 177-182.

Phillips, K.A. (2005). The Broken Mirror: Understanding and Treating Body Dysmorphic Disorder. New York: Oxford University Press.

Phillips, K.A. (2009). Understanding Body Dysmorphic Disorder: An Essential Guide. New York: Oxford University Press.

Phillips K.A. & Diaz, S.F. (1997). Gender differences in body dysmorphic disorder. Journal of Nervous and Mental Diseases, 185, 570–7.

Phillips, K.A., Wilhelm, S., Koran, L.M., Didie, E.R., Fallon, B.A., Jamie Feusner, J. & Stein, D.J. (2010). Body Dysmorphic Disorder: Some key issues for DSM-V. Depression and Anxiety, 27, 573-59.

Phillips, K.A., Menard, W. & Fay C. (2006). Gender similarities and differences in 200 individuals with body dysmorphic disorder. Comprehensive Psychiatry, 47, 77–87.

Phillips, K.A., Didie, E.R., Menard, W., et al. (2006). Clinical features of body dysmorphic disorder in adolescents and adults. Psychiatry Research, 141, 305–314.

Veale, D. (2004). Body dysmorphic disorder. Postgraduate Medical Journal, 80, 67-71.

Veale. D. (2004). Advances in a cognitive behavioural model of body dysmorphic disorder. Body Image, 1, 113-125.