Introduction to Body Dysmorphic Disorder
Many people think of body dysmorphic disorder (BDD) as a relatively new diagnosis, as it is one with which many therapists and physicians are still not entirely familiar. However, the first documentation of the disorder was in 1886 by an Italian researcher by the name of Morselli. He titled the disorder “dysmorphophobia”, or “fear of ugliness”. Since then, there has certainly been more research into BDD, yet its etiology still remains largely unknown, and there is no recorded evidence of any curative treatment.
Definition of BDD
Put simply, BDD is a mental disorder in which the patient obsessively focuses on some physical defect or defects of his or her appearance, whether real or imagined. In BDD, the obsessive nature of the patient’s thoughts about his or her appearance are disproportionate to the size or severity of the perceived defect, if in fact any such defect really exists outside the patient’s mind.
When the BDD patient looks in a mirror, he or she sees things that are not there, and then focuses selectively and intently on the perceived deformity. Quite often these patients are considered by other people to be average in appearance, above average, or even very attractive, yet they see themselves as ugly or deformed.
Diagnosis of BDD
The following is taken from p.468, DSM-IV, 1994, American Psychiatric Association:
Diagnostic criteria for 300.7 Body Dysmorphic Disorder
A. Preoccupation with an imagined defect in appearance. If a slight physical 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 (e.g., dissatisfaction with body shape and size in Anorexia Nervosa).
Many physicians believe BDD is closely related to anorexia nervosa, as part of a class of disorders known as obsessive compulsive spectrum disorders. Unlike anorexia, however, BDD disorder is equally common in women and men. It often has its onset around the time of puberty, although it is often difficult to pinpoint the time of onset, since studies have shown it takes, on average, 9 years to correctly diagnose. Surprisingly, some patients report first experiencing symptoms as early as age 3 or 4.
What Causes BDD?
It is estimated that BDD affects 1-2% of the world’s population, and genetic pre-disposition does appear to be a factor in determining who may develop BDD. Environmental factors, however, can also have an effect on someone with an existing genetic pre-disposition to develop BDD. These factors include severe teasing by peers, and/or a family environment that places either far too much or even far too little emphasis on appearance.
BDD Treatment – Cognitive Behavioral Therapy
Treatment for BDD usually entails a multi-modal approach, beginning with cognitive behavioral therapy, which attempts to get patients to recognize irrational thoughts and then challenge those thoughts with more rational positive self-talk learned in therapy.
Also effective is a type of therapy called exposure and response prevention, commonly used in the treatment of phobias. In this method, patients may be asked to write a list of situations they would normally avoid out of fear or anxiety about their looks. The list is arranged in order from most anxiety-provoking to least, and patients are asked to select an item near the middle of the list. The item should be something that would bring about a certain amount of anxiety in the patient, but nothing severe enough to cause a BDD attack with the potential to lead to obsessive thoughts of suicide or self-mutilating practices. The patient is then encouraged to use the rational self-talk learned in cognitive therapy to face the situation.
The goal is that over time, the patient will begin to see the situation and others like it in a more realistic light, thereby rendering the situation less threatening in the patient’s mind. This sort of approach then can be applied to other items on the list using this same formula.
The component of treatment known as response prevention is all about decreasing the incidence of ritualistic behaviors that have been previously used by the patient to deal with anxiety-producing situations. These behaviors may include compulsively checking the mirror, constantly adjusting one’s outward appearance by applying and reapplying cosmetics, picking at the skin, or even forms of self-mutilation. In most cases, the patient is asked to simply cut down on the amount of time usually spent on these response behaviors, decreasing the time until eventually (ideally) the behavior has ceased altogether.
BDD Treatment – Medication
Another tool used to treat BDD is medication. BDD is a brain disorder which falls under the diagnostic umbrella of “chemical imbalances”. The main neuro-chemical involved in the manifestation of BDD is Serotonin. Therefore, the usual medications of choice in treating BDD are SSRIs (Selective Serotonin Reuptake Inhibitors), traditionally used in treating depression and anxiety, which are also common in BDD patients.
BDD Treatment – Other
Traditional psychotherapy, also known as talk therapy, can also be helpful in relieving anxiety by uncovering and identifying the root causes of that anxiety in the BDD patient’s life. Also, it can often be helpful for the patient to explore more easily accessible “every day” ways of increasing serotonin levels, such as exercise, recreational activities, and/or spending time with a pet.
