Day # 96: Body Dysmorphic Disorder (BDD)

Now that we have completed our thorough discussion of OCD we will move on to discuss the "OCD related disorders" which include body dysmorphic disorder (BDD), hoarding disorder, trichotillomania, and excoriation disorder. Today we will discuss body dysmorphic disorder (BDD).



INTRODUCTION 1


  • Body dysmorphic disorder (BDD) is characterized by an individuals preoccupation with perceived defects/flaws in their appearance.

  • BDD was introduced into the official nomenclature in 1987, however the term dysmorphophobia ("fear of misshapenness or ugliness") was introduced more than a century ago by an Italian psychiatrist (Morselli).

  • These individuals have strong beliefs that they are unattractive or repulsive or grotesque even if flaws are not noticeable or appear minor to others.

  • These beliefs cause significant distress and may lead patients to spend significant time, effort, and/or money trying to correct perceived flaws through cosmetic procedures or plastic surgery.



DIAGNOSTIC CRITERIA 2


  • Preoccupied (obsessional thoughts) about one or more perceived defects/flaws in their appearance.

  • Flaws are not noticeable (or appear minor) to others.

  • Repetitive behaviors or mental acts are performed in response to concerns with their appearance. Examples include excessive grooming, checking in the mirror, camouflaging their perceived flaws, skin-picking, or comparing themselves to others.

  • These preoccupations/behaviors cause significant distress or impairment in functioning (social, occupational, etc.).

  • Symptoms are not better explained by an eating disorder. Example: anorexia nervosa with preoccupation with body fat or weight and associated symptoms.

  • Specifiers: 1) level of insight regarding their beliefs 2) if they have muscle dysmorphia (belief that their body is too small or insufficiently muscular).


EPIDEMIOLOGY / PATHOGENESIS 3


  • Estimates of point prevalence are ~1.5-2.5% and may be slightly more common in women than men.

  • Higher prevalence in dermatologic and cosmetic surgery patients.

  • Median age of onset is 15 years old (two-thirds of individuals have onset before age 18).

  • Risk factors include childhood abuse (including teasing) as well as first-degree relatives with OCD.

  • BDD has been associated with abnormalities in executive functioning and visual processing. Studies have also suggested some involvement in the cortico-striatal-thalamo-cortical (CSTC) circuits that play a role in OCD.


CLINICAL PEARLS 4


  • The onset of symptoms are typically gradual, begin in early adolescence, and tend to be chronic without appropriate treatment.

  • Patients with undiagnosed BDD often feel a lot of embarrassment and shame about their appearance and may not readily disclose their symptoms. They may be more likely to present to a dermatology clinic as opposed to a behavioral health clinic for example. They require careful screening in order to uncover symptoms.

  • Useful screening questions include “Are you very worried about your appearance in any way?” and “Are you unhappy with how you look?”

  • Important questions to consider during evaluation: age of onset; course of symptoms; type and severity of symptoms; extent of insight/impairment; repetitive behaviors or mental acts; skin-picking; attempts to camouflage; cosmetic procedures; avoidance behaviors; presence of comorbid symptoms/disorders; safety assessment.

  • Keep in mind that surgical/dermatological procedures are routinely unsuccessful in satisfying the patient and often worsen their BDD symptoms. This is an important aspect of psychoeducation for the patient.

  • Preoccupations may occur with any area of the body but most commonly focus on features of the face, head, or symmetry of their appearance. Over the course of their illness they are preoccupied with about 5-7 different areas on average.

  • Many patient with BDD have ideas of reference and falsely believe that people are starting at or talking about their flaws.

  • High comorbidity with major depression disorder (most common ~75%), social anxiety disorder, OCD (~33%), substance-use disorder, and suicidality (~80% suicidal ideation).



TREATMENT 5


  • Treatment for all OCD and related disorders are similar, so we have written a detailed post titled "Treatment of OCD" where we discuss treatment options in detail. Please refer to that post for a more thorough discussion.

  • Psychotherapy: Therapy is the mainstay treatment for BDD. CBT for OCD has been modified for BDD and is recommended as first-line management. Core elements of treatment include exposure, responsive prevention, and cognitive restructuring. Additional BDD specific features include targeting visual processing abnormalities such as re-training to develop a more holistic view of their appearance. Motivational interviewing is often needed when addressing ambivalence to psychotherapy. Habit reversal may be needed for related behaviors such as skin-picking and hair-pulling.

  • Pharmacotherapy 6: SSRIs are first-line medications for OCD and related disorders including body dysmorphic disorder. Small trials have found shown modest improvement in symptoms. Clomipramine is also effective. Like OCD, higher doses of SSRIs are often required for treatment response. In treatment resistant cases there is limited data that exists for augmentation with antipsychotics that was not clearly helpful, but it is is still used in clinical practice. See pharmacotherapy section in the "Treatment of OCD" lesson to see additional options.



CONCLUSION


Nice work. Next lesson we will discuss hoarding disorder. Resources for today's post include: Kaplan and Sadock's Comprehensive Textbook of Psychiatry, DSMV, and First Aid for the Psychiatry Clerkship.












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