User:Petermgrund/sandbox/Body dysmorphic disorder

Body dysmorphic disorder (BDD) is a mental disorder characterized by an obsessive focus on perceived flaws or defects in one's physical appearance, which are often unnoticeable or minor to others. When an actual visible difference exists, its importance is disproportionately magnified in the mind of the individual. This preoccupation can lead to significant emotional distress and interfere with daily functioning. Individuals with BDD may spend hours fixated on what they consider to be deformities or blemishes, leading to severe self-consciousness, anxiety, and avoidance of social situations. BDD is distinct from normal concerns about appearance, as it involves excessive self-scrutiny and often results in extreme dissatisfaction, regardless of any reassurance from others.

In addition to thinking about it, those with BDD typically check and compare the perceived flaw repetitively and can adopt unusual routines to avoid social contact that exposes it. Fearing the stigma of vanity, they usually hide this preoccupation. Many seek dermatological treatment or cosmetic surgery, which typically does not resolve the distress. Those experiencing BDD tend to have very high rates of suicidal ideation, described by 57.8% of patients. Around 2.6% of patients attempt suicide each year, making BDD one of the most lethal mental health conditions.

BDD is estimated to affect between 0.7% to 2.4% of the total population. The disorder is equally common in men and women, although milder forms of BDD may be more common in women. It typically emerges in adolescence, a critical period for developing self-image. Research indicates that among individuals with BDD, it is most common to be preoccupied with 5-7 body parts over the course of a lifetime. It is believed that BDD is under-diagnosed.

Although BDD's exact causes are unclear, it's believed to result from a combination of genetic, neurobiological, environmental, and psychological factors. BDD as classified in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), is placed within the obsessive–compulsive spectrum. This categorization underscores the disorder's characteristic features that align with obsessive-compulsive tendencies. Individuals' beliefs about their appearance can vary widely. This spectrum ranges from good intuition, where the person acknowledges the possibility of being mistaken about their perceived flaws, to extreme cases where they hold delusional beliefs about ugliness. These delusions are marked by a strong conviction that one looks unattractive or deformed, despite evidence to the contrary.

Preoccupation with appearance
People with BDD are preoccupied with the idea that some aspect(s) of their appearance is ugly, unattractive, deformed, defective, or flawed in some way. The face or head are frequently disliked, most often the skin (for example, acne, scars, wrinkles, or pale skin), hair (for example, hair thinning or excessive body or facial hair), and nose (for example, size or shape). The preoccupation usually focuses on specific areas but may involve overall appearance, as in muscle dysmorphia (a preoccupation with the idea that one's body is too small or is insufficiently lean or muscular).

BDD preoccupations are time consuming (occurring an average of 3–8 hours a day) and usually difficult to resist or control. Unwanted rumination about appearance is also common and can be highly distressing.

Repetitive behaviors
Nearly all individuals perform BDD-related compulsive or safety behaviors, which aim to diminish the distress caused by thoughts about the perceived flaws (Phillips, Menard, Fay, & Weisberg, 2005). Common behaviors include compulsively comparing the disliked body areas with the same areas on other people, camouflaging the disliked areas (for example, with a hat, hair, sunglasses, posture, makeup), compulsive checking of mirrors and other reflective surfaces, excessive grooming (for example, makeup application, hair styling, shaving, hair plucking), skin picking, reassurance seeking, and excessive exercise or weightlifting. These behaviors are time consuming (usually occurring for many hours a day) and are difficult to resist or control. More recently identified behaviors include tanning (for example, to darken “pale” skin or cover perceived scars or acne), excessive clothes changing, and compulsive shopping (for example, for beauty products, acne or hair-loss remedies, or clothes), which can cause substantial debt (Phillips, 2005a).

Emotional distress and impairments
Studies using standard measures with well-established norms have found that individuals with BDD have markedly poor psychosocial functioning and quality of life. For example, in two studies that used the SF-36, mental health-related quality of life was markedly poorer than for the general U.S. population and even poorer than for patients with clinical depression or a chronic or acute medical condition (e.g., type II diabetes or acute myocardial infarction) (Phillips, 2000; Phillips, Menard, Fay, & Pagano, 2005). Scores on other standard measures similarly reflect very poor functioning and quality of life (Phillips, Menard, Fay, & Pagano, 2005).

Patients usually experience problems in intimate relationships and social functioning because they are embarrassed and ashamed by their supposed ugliness, are anxious around others as a result, and fear being rejected because of how they look. Patients often believe that they are inadequate and unacceptable—e.g., worthless, inadequate, unlovable, and an object of ridicule and rejection (Veale et al., 1996). Impairment in academic or occupational functioning is also common (Phillips, 2005a; Phillips, Menard, Fay, & Pagano, 2005). In a broadly ascertained BDD sample (n = 200), 36% of individuals were not currently working, and 32% were not able to currently be in school or do school work, because of psychopathology (BDD was the primary diagnosis for most) (Phillips, Menard, Fay, & Pagano, 2005).

Prevalence
BDD prevalence varies widely depending on the setting. It's estimated at 1.9% in the general adult community. Among student populations the prevalence is slightly higher, estimated at around 3.3%. This increase might be attributed to the heightened self-consciousness and societal pressures often faced by individuals in academic environments.

In psychiatric settings, the prevalence of BDD shows a notable increase. Among both adolescent and adult psychiatric inpatients, the rate is approximately 7.4%, while in outpatient settings, it is around 5.8%.

Various studies examining the prevalence of BDD in cosmetic settings ranging from 6.3–53.6%,  with an overall weighted prevalence of 13.2%. The prevalence was higher among males (15.3%) compared to females (10.9%). In rhinoplasty surgery settings, based on seven studies with 1,001 participants, the prevalence figures fluctuated between 1.8–31.5%, leading to a weighted prevalence of 20.1%. For orthognathic surgery, two studies with 259 participants showed a BDD prevalence ranging from 10–13.1%. Two studies involving 480 orthodontics and cosmetic dentistry patients found a prevalence range of 4.2–7.5%. Here, females showed a higher prevalence than males. A single study focusing on vulvo-vaginal surgery, specifically labiaplasty, with 49 participants, reported a BDD prevalence of 18.4%.

In general dermatology outpatient settings, five studies with 914 participants revealed a prevalence range from 4.2–29.4%, with a weighted prevalence of 11.3%. Cosmetic dermatology outpatient settings, covered in five studies with 301 participants, showed a prevalence range of 2.9–15.2%, with a weighted prevalence of 9.2%. Finally, in acne clinics, two studies with 287 participants estimated the prevalence of BDD at 11.1%.

Neuro
Several neuroimaging studies have identified abnormalities in thalamic surface morphology and thalamo-frontal functional connectivity in individuals with anorexia nervosa which has similar cognitive features to BDD. Nakajima (2017) and Halassa (2017) both highlight the thalamus's role in regulating functional connectivity within and between cortical regions, which are relevant to the cognitive processes involved in BDD. Feusner (2010) found abnormalities in visual processing and frontostriatal systems in BDD.

Comorbidities
BDD is associated with many comorbidities and, most commonly, psychiatric disorders.. Major depressive disorder, substance abuse disorder, social phobia, and obsessive-compulsive disorder co-occur with BDD, on average, 62%, 39%, 38%, and 33%, respectively.1,33,34 Social media usage increases psychiatric conditions such as depression, body image dissatisfaction, and social networking site addiction. 37 Suicidal ideation was described by 57.8% of BDD patients, with 2.6% of patients attempting suicide each year.

Early onset BDD has been associated with greater psychiatric comorbidity in at least two samples.

SRIs
Serotonin reuptake inhibitors (SRIs) are the preferred medication for BDD, as they help reduce obsessional thinking and compulsive behaviors. These medications include the SSRIs citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac), sertraline (Zoloft), fluvoxamine (Luvox), and paroxetine (Paxil), as well as the tricyclic antidepressant clomipramine (Anafranil). These medications are also effective in treating various psychiatric comorbidies of BDD like OCD, major depressive disorder, and panic disorder. They can also alleviate symptoms like impulsivity, anxiety, aggression, and pain.

Numerous studies have shown the effectiveness of SRIs in treating BDD. For instance, a study comparing clomipramine with desipramine found clomipramine more effective in reducing BDD symptoms and functional disability. Similarly, a trial with fluoxetine versus placebo demonstrated that fluoxetine significantly improved BDD symptoms.

SRIs appear effective for delusional BDD as well as non-delusional cases. Unlike other delusional disorders where antipsychotics are typically used, SRI monotherapy has been found effective for delusional BDD. Retrospective studies suggest antipsychotics alone are rarely effective for delusional BDD, hence the recommendation for treating delusional BDD with an SRI rather than an antipsychotic alone.

While there are no studies comparing different doses specifically for BDD, clinical experience suggests that higher doses than those used for depression might be required. In some cases, doses higher than the maximum recommended by pharmaceutical companies are used. Generally, reaching the maximum recommended dose by the pharmaceutical company by week 5–9 of treatment, if tolerated, is suggested. In terms of SRI trial duration, response usually develops gradually and may not be evident for up to 12-16 weeks. .

Prevalence among BDD patients
Patients with BDD often seek cosmetic procedures. Studies have shown that significant portion (38%) opt for rhinoplasty, followed by breast augmentation (8.2%). Liposuction (12%) and jaw surgery (10%) are also common, more so than breast augmentation and scar revision (9% and 7%, respectively). For less invasive treatments, 50% of BDD patients choose collagen injections and 19.2% go for microdermabrasion. Additionally, up to 75% of BDD patients seek cosmetic dermatologic treatments. While 66% of these patients receive the treatments, 16% report worsened BDD symptoms post-treatment, and 75% feel dissatisfied with the results.

Outcomes of cosmetic procedures
While about 66% of patients with BDD receive some sort of cosmetic treatment, 16% report worsened BDD symptoms post-treatment, and 75% feel dissatisfied with the results.

Some BDD patients use excessive amounts of dermatologic injectables, resulting in visible facial distortion (overfilled syndrome).

Historical perspectives
The term "dysmorphic" is derived from the Greek word, dusmorphíā – the prefix 'dys-' meaning abnormal or apart, and 'morphḗ' meaning shape. Italian physician Enrico Morselli first used the term dysmorphophobia in 1886 to describe people who felt a subjective feeling of ugliness or were tormented by an inperceptable physical deficit. Sigmund Freud (1856–1939), the Austrian founder of psychoanalysis, once called one of his patients, a Russian aristocrat named Sergei Pankejeff, as "Wolf Man," as he was experiencing classical symptoms of BDD.

Evolution of diagnostic criteria
In 1980, the American Psychiatric Association first recognized body dysmorphic disorder in the third edition of its Diagnostic and Statistical Manual of Mental Disorders (DSM) as an atypical somatoform disorder. By its 1987 revision, the DSM-III-R reclassified it as a distinct somatoform disorder under the name body dysmorphic disorder.

The DSM-IV, published in 1994, defines BDD as an excessive preoccupation with an imagined or minor defect in appearance. This preoccupation must cause significant social or occupational impairment and cannot be better accounted for by another disorder, such as anorexia nervosa.

The most recent edition, DSM-5, published in 2013, categorizes BDD under the obsessive-compulsive spectrum. This edition introduces operational criteria, including repetitive behaviors or intrusive thoughts, and recognizes the subtype muscle dysmorphia, which involves a preoccupation with one's body being too small or insufficiently muscular or lean.

Media and online influence
Frequent use of social media is linked to the development of unrealistic body image ideals, increased preoccupation with appearance, and heightened anxiety. A 2019 systematic review concluded that heavy social media use may mediate the onset of sub-threshold BDD. This exposure can also exacerbate preexisting body image dissatisfaction and comorbidities associated with BDD, such as depression and eating disorders. It has been suggested that the constant exposure to edited and filtered images on platforms such as Snapchat and Instagram can lead to a greater desire for cosmetic and plastic surgeries to address perceived defects. In 2018, the plastic surgeon Dr. Tijon Esho coined term "Snapchat Dysmorphia" to describe a trend of patients seeking plastic surgeries to mimic "filtered" pictures. A recent study identified that sensitivity to appearance-based rejection could mediate the relationship between Instagram addiction and dysmorphic concerns in some young adult women.

During the COVID-19 pandemic, the increased use of videoconference platforms like Zoom have led to the "Zoom effect," where constant exposure to one's own image triggers body dissatisfaction and an interest in aesthetic surgery.

Researchers

 * Katharine Phillips
 * David Veale

Support organizations

 * BDD Foundation
 * International OCD Foundation

Condition summaries

 * NHS
 * Mind UK
 * Mayo Clinic

Books

 * A male perspective living with BDD