Body Dysmorphic Disorder (BDD,) also called “imagined ugliness,” is a somatoform psychological disorder. BDD patients have an excessive preoccupation with their physical appearance and/or have an intensely negative body image. Physicians have also classified BDD as an atypical somatoform disorder without diagnostic criteria.
Body dysmorphic disorder, in comparison to other psychological illnesses, is a relatively “young” condition.
The first mention of BDD was by an Italian psychologist in 1886, who dubbed the disorder “Dysmorphophobia
.” Other doctors such as Morselli
in 1891 and Kraeplin
from 1909 to 1915 have written about similar cases of body dysmorphism
. These men called their findings “dermatologic hypochondriasis
” and “beauty hypochondria
,” respectively. Throughout the world, southeast Asia’s koro
is the only imagined ugliness disorder besides BDD. In koro
, men have fears that their penises and women that their labia
, or breasts
, respectively, will recede into their stomachs or chests, causing death. This bizarre fear supposedly has a brief duration, and it differs from BDD in that koro
has a paralyzing fear of death
where in BDD there is none. The American Psychiatric Association
finally recognized BDD as a valid diagnosis in 1987, and since the early 1990s, cosmetic surgeons, dentists, and dermatologists have recognized that their patients who are unnecessarily concerned about a specific physical entity might be able to put a name to their obsessions: Body Dysmorphic Disorder.
The BDD patient’s need for perfection is so great that often their psychological states become noticeable by other people, sometimes even becoming physical manifestations.
People may call the BDD patient “vain;” while those who have normal mental functions may see no reason to be constantly checking one’s appearance, those with BDD are drawn to mirrors, lights, saucepans, glass, etc., as they frequently monitor their appearance. Often people with BDD use classically negative words or phrases to refer to the body part around which their disorder centers. For example, they might say, “I have such a big, crooked nose,” or “fat cheeks", or “bug eyes.” While it is common for people to have some concerns about their physical appearance, especially during adolescence, BDD differs in the level of functionality of the sufferer. Body Dysmorphic Disorder patients can become so agitated with their appearances that their mental states can lead to nervous breakdowns and physical manifestations.
With Body Dysmorphic Disorder, the patient often has feelings of shame, defectiveness, depression, anger, unworthiness, anxiousness, suicidal ideation, frustration, or embarrassment. In short, those with BDD have a preoccupation with a specific body part that becomes so extreme that the person becomes unable to function in daily living. Some extreme BDD behaviors can include but are not limited to: shunning social activities, walking in the dark to stay out of sight, mirror avoidance, hiding bodies with makeup, baggy or long clothing, body position, glasses, wigs, hats, gloves, masks, self-correction, spending from 3-8 hours a day compulsively “fixing,” or a lack of eye contact. In one documented case, a women with BDD bought a motorcycle in order to speed from location to location, wearing a dark helmet, hoping that the rapidity of the vehicle and hiding behind the helmet would prevent pedestrians or fellow motorists from seeing her face. One of the most common practices of a BDD patient is called self-correction. In it, the person attempts to “fix” their cosmetic problem themselves, and can lead to dangerous, self-destructive behavior. Examples of this behavior are face-picking, tweezing, and digging at skin. In rare cases, patients have even attempted to perform surgery on themselves after a cosmetic surgeon, doctor, or dermatologist minimized their concerns and refused to perform a realistically unnecessary operation. One man named “Gary” was concerned about the condition of his skin. In actuality, Gary had what dermatologists consider to be mild teenage acne. After seeing a dermatologist about his skin and receiving a topical medication, Gary still felt that his concerns were not adequately met. He gouged out chunks of the skin on his face with a nail file, trying to “remove the pimples.” Still not satisfied with the result, Gary proceeded to scrape the skin off of his face with sandpaper. Such self-correction can be potentially fatal in extreme cases. In 1999 the American Academy of Family Physicians documented the case of a woman with BDD whose focus of obsession was her neck. In attempting to self-correct her perceived defect, she exposed her carotid artery, nearly killing herself. Another woman, an English lady named Babs Penavler, was disgusted with the veins in the backs of her hands, and in trying to rid her body of the “snakes,” attacked her hands with a knife.
Being a relatively new disorder, BDD is often misdiagnosed.
It has been confused with agoraphobia
, Obsessive Compulsive Disorder
,) Anorexia Nervosa
, social phobia
, Avoidant personality disorder
, Panic disorder
, and any psychotic disorder not otherwise specified
. The reason for this mistaken identity and subsequent misdiagnosis is the aspects of BDD that are parallel to those of other somatoform and factitious disorders
. For example, eating disorders
and BDD are often confused. However, with BDD the problems are imagined or exaggerated, while with anorexia and bulimia, there really is a physical problem present. Also, people with bulimia or anorexia feel better after engaging in their self-destructive behaviors. With BDD, often relief cannot be gained, even with the constant physical scrutiny, preening, etc. The BDD patient is in almost constant distress, as the problem is a self-image
problem. As long as their negative body image persists, there will be little or no permanent relief. Also, anorexia and bulimia generally focus on the patient’s weight, where as BDD usually focuses on a specific body part, usually (but not always) a facial feature. Also commonly confused with BDD is Obsessive Compulsive Disorder, people often failing to differentiate BDD and OCDs because of their close resemblances, such as similar mean age of onset
, recurring behaviors
, and “intrusive thoughts
.” It is for this reason that many doctors treat BDD with the same medications with which OCDs are treated. It is also necessary to note that while many people have been treated for one or more misdiagnosed conditions when in reality, they suffer from BDD, many people have the condition in addition
to other mental illnesses or psychoses
95% have social impairment
87% have academic impairment
60-80% have major depression
67% have suicidal ideation
50% BDD patients undergo surgical correction to fix perceived flaw
39% admitted for psychological evaluation
38% have social phobia
38% display violent behavior
8-37% OCD patients
36% are substance abusers
21-30% attempt suicide
26% are trichotillomaniacs
18% BDD children drop out of school
6-15% cosmetic surgery patients have BDD
11-13% social phobia patients
12% dermatology patients have BDD
12-14% atypical major depression
8% BDD patients are on disability
As noted in the first statistic, 95% of BDD patients have social impairment. There are several reasons for this. Often sufferers feel that others “don’t understand,” “pity them” or “don’t want to hurt their feelings” by not saying anything about their physical appearance. Some people even think that out in public, strangers and passersby are staring, mocking them, or laughing at them. Often BDD patients feel upset because their friends and family minimize or ignore the patient’s “defect.” Those with BDD generally can pinpoint exactly what they feel was the cause of their disorder, such as teasing as a child by a friend, family member, or member of the opposite sex. Other patients attribute their onsets to stress, social pressures, or a childhood trauma. Even though most people with BDD can trace their obsession back to a specific event or period, doctors are not positive of the cause of Body Dysmorphic Disorder. Some feel that biological factors play a role, while others feel that the bases are purely psychological. An approximated 5 million people have BDD, 1.9-2% of Americans. It is estimated that 12% of psychiatric patients have BDD, and 51% of BDD sufferers are male.
Treatment of BDD is still being developed.
The two most effective methods for improvement of quality of life
for those who suffer from Body Dysmorphic Disorder are medication and/or cognitive behavior therapy
). CBT helps people to confront their mistaken beliefs, and 70% of people who underwent the treatment found some improvement. Definitive medications for BDD are still the focus of experimentation. In case studies, several drug classes have been tested. Selective Serotonin Reuptake Inhibitors
) were tested. Selective serotonin reuptake inhibition means that SSRI drugs prevent a drug called serotonin
from being taken into neurotransmitter
cells in the brain. Common SSRIs are Celexa
, and Zoloft
. Generally such medications are used to treat OCDs, depression, panic disorder, generalized anxiety disorder
, and Posttraumatic Stress Disorder
). Also in this class of medication are drugs such as Enafranil
, and Cymbalta
, the latter a new drug being made by Lilly
that is still waiting approval from the FDA
. These drugs are not often prescribed, as they are used primarily for severe, refractory cases; refractory illnesses
are those that are unresponsive to all other methods of attempted treatment. Other “cousins” of SSRIs were tested, such as Effexor
. Medications that are similar to, but not identical to, SSRIs are sometimes called “cousins” because they are hybrids of medications that only uptake serotonin and those that have an uptake of serotonin and norepinephrine
. Also tested were other classes of drugs used to treat other psychiatric illnesses. Lithium
is a mineral commonly used to treat bipolar disorder
and maniac depression
, such as Phenyton
, are used to treat epileptics
is an antianxiety medication, but is not often used anymore; it is considered an old tricyclic antidepressant
, meaning that it had many side effects and since it was created, better alternatives have been found. Benzodiazepines
, such as Valium
, are a class of anxiety drugs that were also tested. The SSRIs exhibited a limited response in 58% of the test subjects, while lithium, neuroleptics, trazadone, and benzodiazepines were ineffective. In a study by Dr. Hollander and colleagues, the medications that proved somewhat effective improved patient preoccupation with body image, the severity of the symptoms, and repetitive behaviors
. However small, any improvement is marked because BDD patients generally have a high rate of functional disability
due to their psychosomatic illness
. Other treatment measures such as supportive psychotherapy
, surgery, and nonpsychological medical treatments
have been ineffective.
“[It’s] incomprehensible to understand what [these] people go through,” Chris Saville, whose son Glen committed suicide after a long battle with BDD
Could you have BDD?Are you concerned with your appearance in any way? If so, what is your concern?
Does this concern preoccupy you? This is, you think about it a lot and wish you could worry about it less?
Have your appearance concerns caused you a lot of distress?
What effect has this preoccupation with your appearance had on your life? Has it significantly interfered with your social life, schoolwork, job, other activities, or other aspects of your life?
Have your appearance concerns affected your family or friends?
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Duggan, Don. Personal Interview. Conducted by Erin Duggan. 09, May 2004.
Duggan, Erica, Personal Interview. Conducted by Erin Duggan. 09, May, 2004.
Grenett, Scott. "If Only You Could See What I See: An Intimate Portrayal of BDD >[cass]." Obsessive Compulsive Foundation, Nashville. 1998.
Kirchner, Jeffrey T. "Treatment of Patients With Body Dysmorphic Disorder." American Family Physician (2000). 25 March 2004 http://www.aafp.org/afp/20000315/tips/8.html
Penavler, Babs. "The Worried Well." Body Dysmorphic Disorder. Films for the Humanities & Sciences, Princeton, NJ. 1997. Video Archive. 2004.
Phillips, Katharine A. "Body Dysmorphic Disorder." Somatoform and Factitious Disorders. Ed. Katharine A. Phillips. Washington, D.C.: American Psychiatric Publishing, Inc., 2001. pp. 67-94.
Saville, Chris. "The Worried Well." Body Dysmorphic Disorder. Films for the Humanities & Sciences, Princeton, NJ. 1997. Video Archive. 2004.
Walker, Pamela. Everything You Need To Know About Body Dysmorphic Disorder. New York: The Rosen Publishing Group, Inc., 1999.